Roche, Edward L. rrnTON' OF QUEEN4,5BU Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director15/ m 10 rl
Name .C,�4) ��C Case #
Date of Cremation ' a
Time Cremation Started `4��e idIA4
Time Cremation Completed
Type of Container �,Dk
Remarks :
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TOWN OF QUEENSBURY
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 Reg lations to Cremate the remains of:
o�
(Name) r l (Sex)
,z LGU J L a
(Street) (City) tate) (zip)
20 �f
who died on day of 7-C 1
at
(Place) (Address)
Name and address of nearest relative or name of person Authorizing cremation:
ry).f t�' 6L'am
(Name) (Address)
Relationship to the deceased C&-LAS'`
Name of Funeral Home
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or 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 remains and to
direct the disposition of the cremated remains, that any personal possessions have either been removed
or may be destroyed, and agree to protect, defend and save harmless Pine View Crematorium from any
and all claims and demands for loss or damages which may be made against them by reason of or
connected with the cremation of said remains as directed,whether such claims or demands are or are not
wholly groundless, false or fraudulent.
(Witness) (Address)
X ( gnature o Relative 6r Legal Rep hd Address))
Signed on this date:
AUTHORIZATION FOR CREMATION AND DISr"o-A L% - .
PORTANT PROVISIONS CONCERNING CREMATION.
N I :THIS IS A LEGAL DOCUMENT.IT CONTAINS IM
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 know of III livi erson w o ha su erior
r authorize the cremation,processing and disposition of the remains of
AA
priority right under state law,to ame o ecease
(hereinafter referred to as the"Deceased"). Da of De Time of Death A M P.M.
Mi `� e�.- _ (herein r referred to as the "Funeral Home")to take
I/We hereby request and authorize l G f— ame o anera nm
possession of and make arrangements for the cremation of the remains of the Deceased at
Name ol Mmatory
(hereinafter referred to as the"Crematory").
to the possession and custody of the Funeral Home.
I/We hereby authorize the Crematory to returnof the C ema ory shall be fulfilled the cremated remains of the ewhen the cremated remains of the deceased are returned to he
I/We understand that the services and obligations
authorize the Funeral Home to arrange for the disposition of the cremated remains oft e
possession and custody of the Funeral Home.I/We hereby
Deceased as follows:
Is special handling required? �.Yes � No Describe
Suitable for shipping: _ Yes -_No
Description of urn or container selec Cemetery
)(Deliver to ame an ress o eme ery
Release to family o e",ve remat emams
Scattering at sea by Funeral Home or Funeral Home's agent
Ship via U.S.Registered Mail*
To:Name Address
Other
L neral Home andCrematoryarenot responsible for any loss or damage of cremated remains shipped via Registered Mail with the United fates
stal Service. sing
ains of the Deceased performed
ance with
The cremation,wsothe rulesnregulationsd and policieis of the Crematory and Funeral Home a d the followng terms and reonditions:
all governing la
in a combustible, lea
1. The remains of the Deceased will not be accepted for cremation unless received by the Crematory
resistant,rigid cremation container.The Crematory is authorized to remove and dispose of handles,ornaments and any other
noncombustible items attached to the cremation container prior to cremation. In the event the remains of the Deceased are
received by the Crematory in a casket or other container constructed of metal,fiberglass,or other noncombustible materials,
I/we authorize the remains of the Deceased to be removed prior to cremation and placed in a combustible cremation container.
I/We further authorize the Funeral Home or Crematory to make disposition of any such noncombustible casket in any lawful
manner it deems appropriate.
2. Mechanical or radioactive devices implanted in the remains of the Deceased (such as pacemakers, etc.) may create a hazard
when placed in the cremation chamber. The Crematory will not cremate any human remains which contain any type of
implanted mechanical or radioactive device. In the event the remains of the Deceased contain such a device I/we hereby
authorize the Funeral Home, sand employees,to remove any such mechanical devices from the remains of the Deceased
prior to cremation, and dis ose o s items at its discretion. I/WE HEREBY CERTIFY THAT THE REMAINS OF THE
DECEASED DO DO OT.(y '� TAIN ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE.
Please initi o��►Ie.
Listed below are all implanted m anical and radioactive devices which the Funeral Home is authorized to remove from the'
remains of the Deceased prior to cremation,and dispose of as indicated:
Description of Implanted Device Disposition
Description of Implanted Device Disposition
If no inWi etion-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 will be totally an
irreversibly destroyed by prolonged exposure to intense heat and direct flame.I/We authorize the Crematory to open the crematio i
chamber during the cremation process and reposition the remains of the Deceased in order to facilitate a complete and thorough
cremation.
4. Certain items,including,but not limited to body prostheses,dentures,dental bridgework,dental fillings,jewelry,and other persona'
articles accompanying the remains of the beceased,may be destroyed during the cremation process. a further authorize that"
any items, other than the cremated remains of the Deceased,are recovered from the cremation chamber,they may be separate
from the cremated remains of the Deceased and disposed of by the Crematory.
5. I/We herebT authorize the Crematory to separate and remove from the cremation chamber all noncombustible materials,includin�
but not limited to,hinges,latches,nails,jewelry and precious metals,and to dispose of such materials.
6. Following cremation,the cremated remains of the Deceased,consisting primarily of bone fragments,will be mechanically pulverizes
to an unidentifiable consistency prior to placement in an urn or other container.
7. Unless an urn or container suitable for shipment is purchased,the Crematory will place the cremated remains of the Deceased in
container which is not designated for any type of shipment.
8. In the event the urn or container is insufficient to accommodate all of the cremated remains of the Deceased,any excess cremate
remains will be placed in a secondary container and returned to the Funeral Home,together with the primary urn or container.
9_ I/Wp rtndorctand and neknowledpp_that even with the exercise of reasonable care and the use of the Crematnrv's hpct Pffnrtc it
SULLIVAN- AVIAN &POTTER FUNERAL HOME
407 Bay Road
Queensbury,NY 12804
(518)792-2067
"Customer's Designation of Intentions"
Name of Deceased:
Cremation: V/
(Scheduled Date) (Location)
Manner of Disposition of Cremated Rpmai
Burial at C0-1/- El Return to Family
F-1 Entombment at El Other (specify):
I hereby designate the Disposition of Cremated Remains and acknowledge receipt of a copy of,,.
this form.
(Signature)
-,o / /(4�, Juq
(PrintedName) (Relationship to Deceased)
(Address)
7;7,7,
(Telephone Number)
"Cremated Remains which shall not have been claimed within 120 days from the dates
cremation may be disposed of by this firm by placement in a columbarium."
Uk20
Printed N me of Funeral Director Sid re of Funeral Director Date
or Undertaker or Undertaker
TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF CREMATED REMAINS
Cremation:
(Actual Date) (Location of Crematory)
Disposition of Cremated Remains: (Manner of Disposition)
(Location)
(Date)
Name of Person Making Disposition Signature Date
#9 WHITE:Funeral Home Copy YELLOW Family Copy PINK:Crematory Copy CUSINTEN Rev.4/96