Amico, Dominic rrO J+N OF QUEENSBU-'kY
,x
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name ) Nn ' t� 1& P/K j (�, Case # 3 0 Cj
4
Date of Cremation -2-Uc, \
Time Cremation Started
Time Cremation Comoleted
Type cf Container 'Uc,149c)
Remarks : �, �. rt L6��✓��
n
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 Regulations to Cremate the remains of:
ame) (Sex)
p Pore / > 7G i clrn d; IV :J
(Street) (City) (State)" (zip)
who died on Z 5X day of YY7 ct„ 20 o 1
at G'
(Place) (Addre )
Name and address of nearest relative or name of person Authorizing cremation:
P i 'L )9 m i c-c 'PC crc C 4\3 Y
(Name) (Address)
Relationship to the deceased J.A s , c
Name of Funeral Home 4 C:-> X QC-) I-)
49
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or has no 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 8f§osition of the cremated remains, that any personal possessions have either been removed
or may bw agiroyed, 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
connectgd�yith the cremation of said remains as directed, whether such claims or demands are or are not
wholly 'tc�u`4idtess, false or fraudul t.
(Witness) (Address)
ignature of Relative or Legal Rep. and Address))
*igned on this date: / Ot
REGAN &DENNY ORAL SERVICE
53 Qs*w Rord
Quun Now Y 0k 12W4
(518)792-1114
"Customer's Designation of Intentions"
Name of Deceased: Tx, „,z 6 , , . )r �,,•,, c
Cremation• ,
ic
(Scheduled.Date) (Location)
Manner of Disposition of Cremated Remains:
❑ Burial at Return to Family
❑ Entombment at ❑ Other (specify):
I hereby designate the Disposition of Cremated.Remains and acknowledge receipt of a copy of
this form. j
i
(Signature)
P-Pa _ Yz —r s e n
(Printed Name) (Relationship to Deceased)
PO LEI e�� 1 -7 L
(Udress)
S/P - 9Yu- 93 S3
(Telephone Number)
"Cremated. Remains which shall not have been claimed. within 120 days from the date of
cremation may be disposed of by this firm by placement in columbarium."
J_ J/a..� � t'Y7G.xJe tr' �•^ ° �� -.•'' 1.^YJ vQ ^a j ����J
Printed Name of Funeral Director Signature of Alnral Director D
or Undertaker or undertaker
TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF CREMATED REMAINS
(Actual Date) (Location of Crematory)
_ r...
; f Cremated Remains:
(Manner of Disposition)
(Location)
(Date)
Name of Person Making Disposition Signature Date
WHITE:Funeral Home Copy YELLOW Family Copy PINK:Crematory Copy CUSINTEN Rev.4/96
AUTHORIZATION FOR CREMATION AND DISPOSITION 031 Rev.4/98
�0���
NOTICE:THIS IS A LEGAL DOCUMENT.IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION.
CREMATION IS IRREVERSIBLE AND FINAL.READ THIS DOCUMENT CAREFULLY BEFORE SIGNING.
UWe,the undersigned,certify,warrant and represent that Uwe have the full legal right and authority,and know of no living person who has a superior
priority right under state law,to authorize the cremation,processing and disposition of the remains of D o r»o,c k )m't c a
ame oease
(hereinafter referred to as the"Deceased").
Date of Death S OF G a i Time of Death A.M. - P.M.
UWe hereby-request and authorize uArtin — � a ae"i l ;y,.� (hereinafter referred to as the "Funeral Home")to take
~ am unera ome
possession of and make arrangements for the cremation of the remains of the Deceased at )O;,2
(hereinafter referred to as the"Crematory"). Name o rematZ�ory
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? 'I i Yes XNo Describe
Description of urn or container selected: Suitable for shipping: `- Yes 7 No
Deliver to Cemetery
ame and Address Of eme ery
- Release to family
Name of DesignatedFamily Member to Receive Cremated Remains
-: Scattering at sea by Funeral Home or Funeral Home's agent
Ship via U.S.Registered Mail*
To:Name Address
i Other
*Funeral Home and Crematory are not responsible for any loss or damage of cremated remains shipped via Registered Mail with the United States
Postal Service.
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 disppose 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,i nts and employees,to remove any such mechanical devices from the remains of the Deceased
prior to cremation, an o su .tems at its discretion. I/WE HEREBY CERTIFY THAT THE REMAINS OF THIS
DECEASED DO LD(;�N06i CON IN ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DEVIC',
Plea
Listed below are all implanted mechanical and radioactive devices which the Funeral Home is authorized to remove from..t:
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
3. The cremation container containing the remains of the Deceased will be placed in the cremation chamb ne
irreversibly destroyed by prolonged exposure to intense heat and direct flame.I/We authorize the Cremator `„chamber during the cremation process and reposition the remains of the Deceased in order to facilitate a c6%401 be fo .
cremation. a�hecre ��
4. Certain items,including,but not limited to body prostheses,dentures,dental bridgework,dental fillings ewelk
articles accompanying the remains of the beceased,may be destroyed during the cremation process.I/We fu r` :1pe a
any items,other than the cremated remains of the Deceased, are recovered from the cremation chamber,the ay aYate'`4
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,incluu.?,,
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.
o I/WP nndpi-Onnd and acknowledge.that even with the exercise of reasonable care and the use of the Crematory's best efforts,it is