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Lockhart, Howard OF QUEEVBUjr�Y PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Directory/r � /QN� Name �� ��/��7— Case # Date of Cremation Time Cremation Started Time Cremation Completed/off ado Type of Container ��,( � Remarks : / A-1 I'd -,36 r9 ,AJ1 Al) I /} TOWN OF QUEENSBURY . PINE VIEW CEMETERY& CREMATORIUM - Quaker Road, Queensbury, New York, 12804 Phone (518)'Crematorium 745-4477 of no answer Cemetery 745-44-76 AUTHORIZATION TO CREMATE The undersigned requests and authorizes Pine View Crematorium, in Accordance with and subject to its R7and Regulations to Cremate the remains of: OWAP.0 A ,2,00ejYXR AAL-- (Name) (Sex) (Street) (City) (State) (Zip) who died on R 1, day of 1t Z� 200 at__k A 44'-rfi� Av&'v V (Place) (Address) N me and address of nearest relative or name of person Authorizing cremation: ZA 6E�aL �00&lpr RT, (Nam ) (Address C- Relationship to the deceased r Name of Funeral Home ^N E IMPORTANT: I represent that to the best of my knowledge, the deceased has o has no acemaker 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 =17r,fra00uIer#. 4"�A //U� Rup Wit ss ddress 46 (Signature of Relative or Legal Rep. and Address)) Signed on this date: �� SMGLETON-BEAIX rUNUAL ROME :G 407 boy XoW Quccusbwy,N''Y`12804 y _ (S l8)793.4439 "Customer's Designation of Intentions" Name of Deceased: Jln u) A, �ne-..k L I >,- -1,j a a Cremation: ��y „��(} ' (Scheduled Date) (Location) Manner of Disp 'tion of Cremated.Remains, Burial at V G= Return to Family ❑ Entombment at ❑ Other (specify): I hereby designate the Disposition of Cremated.Remains and aclmowledge receipt of a copy of this form. (.S'igna ) T d Na e) ( elationship to Deceased) S7" �a (Address) 21 (Telephone Nu—her) "Cremated. Remains which shall not have been claimed. within 120 clays from the slate of cremation may be disposed of by t 's fi=byce enL' a columbarium." Printed Name of Funeral Director Signature of Funeral Director Date or Undertalzer 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 Malting Disposition Signature Date #9 WHITE:Funeral Home Copp YELLOW Family Copy PINK:Crematory Copy CU5INTEN Rev.4/96 PC y� AUTHORIZATION FOR CREMATION AND DIS POSITION 031Rev.4/98 AL DOCUMENT.IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION. E�!=CREMATION EVERSIBLE AND FINAL.READ THIS DOCUMENT CAREFULLY BEFORE SIGNING. I/We,'lhe undersigned,certify,warrant and represent that Uwe have the full legal right and authority,anAlknow priority right under state law,to authorize the cremation,processing and disposition of the remains of ° fvl Per o�ho s ri (hereinafter referred to as the°°Deceased"). -// �,.t �ame o ecease � Datepf Death � ��—w Time of Death ,�3® UWe hereby request and authorize //(� /// A.M. EM. possession of and make arrangements for the cremation of the remains ra o the Deceased at he1`reinafter ferred to as the "Funeral Home")to take (hereinafter referred to as the"Crematory"). N ame o ma retory 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? LJ Yes )<No Describe Description of urn or container lected: Deliver to � �i / Suitable for shipping: " Yes No Release to family a an o eme.. Cemetery ameScattering at sea by Funeral Home or Funeral Home's agent o es�gnat am.y em r to ecerve remate emams 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 th Postal Service. e United States The cremation,processing and disposition of the remains of the Deceased authorized herein shall be performed in accordance with all governing laws,the rules,regulations and policies of the Crematory and Funeral Home,and the following terms and conditions: 1. The remains of the Deceased will not be accepted for cremation unless received by the Crematory in a combustible, leak 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 t e 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,its agents and employees,to remove any such mechanical devices from the remains ofthe Deceased prior to cremation, and dispose of such items at its discretion. I/WE HEREBY CERTIFY THAT THE REMAINS OF THE DECEASED DO _ DO NOT XCONTAIN ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE. Please initial one. Listed below are all implanted mechanical 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 instruction-for disposition is given,such items may be disp_Qsv"f 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 and irreversibly destroyed by prolonged exposure to intense heat and direct flame.I/We authorize the Crematory to open the cremation 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 .ewelry,and other personal articles accompanying tie remains of the eceased,may be destroyed during the cremation process.I/ie further authorize that if any items, other than the cremated remains of the Deceased, are recovered from the cremation chamber,they may be separated from the cremated remains of the Deceased and disposed of by the Crematory. 5. I/We hereby authorize the Crematory to separate and remove from the cremation chamber all noncombustible materials,including, 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 pulverized 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 a 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 cremated remains will be placed in a secondary container and returned to the Funeral Home,together with the primary urn or container.