Braman, Luella N
T07+N OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director 3�
Name 1—U {- �Lh Case # c��'
Date of Cremation
Time Cremation Started i 3 NL
Time Cremation Completed
Type of Container lent) r) ` � �b5r-9 '0 b�
Remarks : C&O L '-Do1) ice" -1 . E L
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TOWN OF QUEENSBURY
(\ r ) PINE VIEW CEMETERY&CREMATORIUM
Quaker Road, Queensbury, New York, 12804
Phone(518) Crematorium 745-4477 of no answer Cemetery 745-4476
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, in Accordance with and subject to its
Rules and Regulations to Cremate the remains of:
(Name) (Sex) 1
(Street) (City) (State (zip)
who died on /� day of 2061' A
at
I
(Place) (Address)
Name and address of nearest relative or name of person Authorizing cremation:
4,� 6=& �"/,q
(Name) (Address)
Relationship to the deceased z 1'
Name of Funeral Home _ - 2—
IMPORTANT:
i
I represent that to the best of my knowledge, the deceased has o as n pacemaker in his or her body.
(Circle One)
I certify that I have the full power and authorization to arrange For the cremation of the remaina and to
direct the disposition of the cremated remains, that any personal possessions have either been_rer:&ave1__M
or may be destroyed, and agree to protect, defend and save harmless Pine View Cromat�Urn from any
and all claims and demands for loss or damages whiat. may--be_made against them by reason of or
connected with the cremation of said remains as directed, whether such claiins or demands are or are not
wholl groundless, fals r fraudulent.
(Witn s) (Addres )
(Signature of Relative or Legal Rep. and Address))
`his date:
I
I
I
G� 0311tev.4/98
oa�w AUTHORIZATION FOR CREMATION AND DISPOSITION �'
NOTICE:THIS IS A LEGAL DOCUMENT.IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMAVI
CREMATION IS IRREVERSIBLE AND FINAL.READ THIS DOCUMENT CAREFULLY BEFORE SIGNING.
I/We,the undersigned,certify,warrant and represent that I/we have the full legal right and authority,and knew no►iving p son who has a superior
priority right under state law,to authorize the cremation,processing and disposition of the remains of ame o eeease7i
(hereinafter referred to as the"Deceased"). G 3
Date of Death // r/i' / Time of Death / /'�A.M. , P.M.
01
I/We hereby,request and authorize G� _ �'/!tip^�`""'K- (hereinafter referred to as the "Funeral Home")to take
ame o uner ome /
possession of and make arrangements for the cremation of the remains of the Deceased at / ame o rematnry
(hereinafter referred to as the"Crematory").
I/We hereby authorize the Crematory to return the cremated remains of the deceased to the possession and custody of the Funeral Home.
I/We understand that the services and obligations of the Crematory shall be fulfilled when the cremated remains of the deceased are returned to the
possession and custody of the Funeral Home.I/We hereby authorize the Funeral Home to arrange for the disposition of the cremated remains of the
Deceased as follows: ]�/�
Is special handling required? -- Yes `X No Describe
Description of urn or container selected: Suitable for shipping: - Yes No
n A/1_ �_ r�steter}•
—i Deliver to ame and Ad0reSS ot"Leme ery
Release to family
ame o esignated Family Member to ecerve remate emams
Scattering at sea by Funeral Home or Funeral Home's agent
Ship via U.S.Registered Mail*
To:Name Address
-
Other `'--
*Funeral Home and Crematory are not responsible for any loss or damage of cremated remains shipped via Registered Mail with the Unite tates
Postal Service. - I
The cremation,processing and disposition of the remains of the Deceased authorized herein shall be performed in accordanck;witt
all governing laws,the rules,regulations and policies of the Crematory and Funeral Home,and the following termspd condiu is
1. The remains of the Deceased will not be accepted for cremation unless received by the Crematory in a combustible, veal
resistant,rigid cremation container.The Crematory is authorized to remove and dispose of handles,ornamen°ts and any other
noncombustible items attached to the cremation container prior to cremation.In the event the remains of the Deceased ar
received by the Crematory in a casket or other container constructed of metal,fiberglass,or other noncombustible materi::
I/we authorize the remains of the Deceased to be removed prior to cremation and placed in a combustible cremation contain:.
I/We further authorize the Funeral Home or Crematory to make disposition of any such noncombustible casket in any law`
manner it deems appropriate.
2. Mechanical or radioactive devices implanted in the remains of the Deceased (such as pacemakers, etc.) may create a bazar
when placed in the cremation chamber. The Crematory will not cremate any human remains which contain any type
implanted mechanical or radioactive device. In the event the remains of the Deceased contain such a device I/we her-x
authorize the Funeral Home,its agents and employees,to remove any such mechanical devices from the remains�ofthe D c,
prior to cremation, and dispose of such items at its discretion. I/WE HEREBY CERTIFY THAT THE REN r.,, s���fi,
DECEASED DO DO NOT CONTAIN ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTI��F-nE.a
Please initial ofie.�-
Listed,below are all implanted mechanical and radioactive devices which the Funeral Home is authorized to remove fro
remains of the Deceased prior to cremation,and dispose of as indicated:
Description of Implanted Device Disposition
Description of Implanted Device Disposition
If no instruction for disposition is given,such items may be disposed of at the discretion of the Funeral Home.
3. The cremation container containing the remains of the Deceased will be placed in the cremation chamber and wilk Ise totally
irreversibly destroyed by prolonged exposure to intense heat and direct flame.I/We authorize the Crematory to ;-,I the crema
chamber during the cremation process and,reposition the remains of the Deceased in order to facilitate a cop.�' , d thord
cremation.
4. Certain items,including,but not limited to body prostheses,dentures,dental bridgework,dental fillings,*ewetry,and other per s
articles accompanying the remains of the beceased,may be destroyed during the cremation process.We farther authorize W
any items, other than the cremated remains of the Deceased, are recovered from the cremation chamber they ma3.be se;
from the cremated remains of the Deceased and disposed of by the Crematory. - �udm�
5. I/We herebT authorize the Crematory to separate and remove from the cremation chamber all noncombustible teri4l,-
but not limited to,hinges,latches,nails,jewelry and precious metals,and to dispose of such materials. Ak.. Averil
6. Following cremation,the cremated remains of the Deceased,consisting primarily of bone fragments,will be mechan:rall
to an unidentifiable consistency prior to placement in an urn or other container. — ,ed
7. Unless an urn or container suitable for shipment is purchased,the Crematory will place the cremated remains 0%t a necea
contain
ch
eevent t'he-is
or-desteent�designated
is- any
ffici nt to accom shipment.
modate all of the cremated remains of the Deceased any
8. In the "
remains will be placed in a secondary container and returned to the Funeral Home,together with the primary
;
mer's Designation of Intentions"
sed: t ,
emation
(Scheduled Date) (Location)
Manner of Disposition of Cremated.Remains:
Jk Burial at -r ,� _-,x. f c-� .-. ElReturn to Family
Q Entombment at ❑ Other (specify): #
I hereby designate the Disposition of Cremated.Remains and acknowledge receipt of,k 6-py of
this form.
(Signature)
i
(Printed Name) (Relationship to Dec i i.') wer`
�'• i i
(Address)
(Telephone Number)
"Cremated. Remains which shall not have been claimed. withi*.120 day=
cremation may be disposed of by this firm by placement i a Columba
Printecl�lVame oun`er`la Director -
i'
or UnderL ker or'Undertaber
TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF D
Cremation: r
(Actual Date) (Location of Crenlato
Disposition of Cremated.Remains:
(Manner of Disposition)
(I,oj�6on)
� s
fJ t j'-
(Date)
i
Name of Person Making Disposition Signature Date t. vlf
i
#9 WHITE:Funeral Home Copy YELLOW.Family Copy PINK-.Crematory Copy CUSINTEN Rev.