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Christman, Douglas T07+N OF QUEENB PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 �l Funeral Director Name �[/W6,�- j (f1R- S-t111 e10 Case # 3 / Date of Cremation �9 _ G Time Cremation Started 1 Time Cremation Comoleted �7 4 C2,� V Type of Container GV-N-1 0j0ttt&P1.z"f0=/- — ze, iv�J�5 C� /-VO ,V Remarks : C'R k(o pocz� V�5,4-- d r- Ll 10 ✓k e; c 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: L A LAB L tScHc! M�a-�.L`� _. (Name) (Sex) '. (Street) (City) (State) (zip) who died on day of at MIS KOS iA (Place) (Address) Name and address of nearest relative or name of person Authorizing cremation: lvklu, "'l..i_L �(3kal i(A uc'r(o/,/ e 1 ��,G NS (n!_1S (Name) (Address) Relationship to the deceased__ ail( 111 Name of Funeral Home 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 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. V4"Jj Y/V," LZ (Witr}ess) A (Address) or Legal Rep. and Address)) Signed on this date:_ irc Q Ct� AUTHORIZATION FOR CREMATION AND DISPOSITION N—Q�:THIS IS A LEGAL DOCUMENT.IT CONTAINS IMPORTANT PROVISIONS CONGER CREMATION IS IRREVERSIBLE AND FINAL.READ THIS DOCUMENT CAREFULLY BEFORE o3'Re"'a/�s I/We,the undersigned,certify,warrant and represent that Uwe have the full legal right and authority, NING CRF,MATIOii, priority right under state law,to authorize the cremation SIGNI�ti(;, (hereinafter referred to as the"Deceased"), 'Processing and disposition of the remains of and know of no living person who has � / ��� n � ra!or, Date of Death /. / 1 / +� ameo cea� I/We hereby request and authorize �, — � ,LoSG�D__�_Time of Death a. Al _L�L. itl�l A.M. Possession of and make arrangements for the cremation of (hereinafter referred to as the" the remainsof the Deceased at orFu ((hereinafter referred to as the m "Funeral Hoe")to take Crematory"). I/We hereby authorize the Crematory to return the cremated remains of the deceased to the Possession ameo r We understand that the services and obligations of the Crematory shall be fulfilled when the cremated remainsand Possession and custody of the Funeral Home.I/We hereby authorize the Funeral Home to arrange for the disposition of custody of the Funeral Home. Deceased as follows: of the deceased are returned to the Is special handling required? -, Yes ? No Describe the cremated remains of the Description of urn or container selected: Deliver to Suitable for shipping: ❑ yes j No A Release to family .Y ame an ress o eme uy Cemetery Scattering at sea by Funeral Home or Funeral Home's agent es�gnat ami y em to ecerve remate emams Ship via U.S.Registered Mail* To:Name Other Address *Funeral Home and Crematory are not responsible for any loss or damage of cremated remains shipped via Registered Mail wit=UnitedStates Postal Service.The cremation,processing and disposition of the remains of the Deceased authorized herein shall be pperformed in actor all governing laws,the rules,regulations and policies of the Crematory and Funeral Home,and the followin ter I. The remains of the Deceased will not be accepted for cremation unless received by the Crematory t a s and accordance le, with g terms and conditions: resistant,rigid cremation container.The Crematory is authorized to remove and dispose of handles,ornaments and an 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 manner it deems appropriate. such noncombustible casket in any lawful Z. Mechanical or radioactive devices im when placed in the cremation chain planted in the remains of the Deceased (such as pacemakers, etc.) may create a ber. The Crematory will not cremate any human remains which contain an type of hazard y 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 oithe 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 CONTAIN 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: Desuiptiom or implanted Device Disposition Description or Implanted Device Disposition If no instruction for disposition is given,such items may be disposed of at the discretion of the Funeral Home. 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. Curtain items,including,but not limited to body prostheses,dentures,dental bridgework,dental fillipgs 'ewelry,and other personal articles accompanying the remains of the&ceased,may be destroyed during the cremation process.Ie further authorize that if any items,other thm 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. L'We herebpauthorize 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. Followmg ration,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. 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. �nntain,-r iq insufficient to accommodate all of the cremated remains of the Deceased_anv Pxeeaq rri mat,,d •.4' "Customer's Designation of Intentions" r Name of Deceased: K(its t tv\,` )J Cremation: (Scheduled Date) (Location) - r: 0, L Manner of Disposition of Cremated Remains: ❑ Burial at X Return to Family ❑ Entombment at - - ti ❑ Other (specify: I Hereby designate the Disposition of C emated Remains and acknowledge receipt of a Copy of this form. 11-46W, (Si re r (Printed Name) (Relationship to Deceased) I`i 0 n:`la At s (Address) (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 a columbarium." Printed Name of Funeral Director Signature of Funeral r ate 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) - X of Person preposition Signature Date v wiRiE.Funeral Home Capp YELLOW:Family Copy PINK:Crematory Copy CUSINTEN Rev.4/96