Shefrin, Anne TOWN OF QUEEVBU.�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name &4'10 J#* AA�, R tN Case #
Date of Cremation X— /0-- oZC7z f
Time Cremation Started M
Time Cremation Completed
Type of Container � �
Remarks : G Ll7wXV
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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 Cernetery745-4476
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, in Accordance-with-and s6bj;&t'to its
R(ulleesn and Regulations to Cremate the remains of: (�
ne
(Name) (Sex)
(Street) (City) 1 (S te) (zip)
who died on I LJ� day of 20��
at •
(Place) (Address)
r•
Name and address of nearest relative or name of person Authorizing cremation:
-fi,uskJ) Sh4(- ( n
(Name) (Address)
Relationship to the deceased
Name of Funeral Home e G� C 1'11'ti
IMPORTANT:
I represent that to the best of my knowledge, the deceased has has 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 remains and to
direct the disposition of the cremated remains, that any personal possessions have either been remove
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)
(Signature of Re ative ortyegal Rep. and Address))
Signed on this date: �%\V I
+ RE►GAN&DENNY FUNERAL SERVICE
33 Cuabw Road
Qwwsbury,New York 12804
(318)792-1114
"Customer's Designation of Intentions"
Name of Deceased.:
Cremation: .,:`
(Scheduled Date) (Location)
y
Manner of Dispeition of Cremated. I�,e?nains:
1 ,1} i,
Burial at t t �J � �* *«- '�°!. ❑ Return to Family
❑ Entombment at ❑ Other (specify):
I hereby designate the Disposition of Cremated.Remains end aclmowledge receipt of a copy of
tins form. r /f
( i nature) {�
s (Printed.Name) (Relationship to Deceased)
(Address)
(Telephone Numher)
"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."
r r
Printed Na a of Funeral Director SignaturO Funeral Director bat.
Undertaker or'fJndertaker
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
031Rev.4198
r ND WSPOSITION
rw� AUTHORI7ATION FOR CREMATION A
� A LEGAL DOCUMENT.IT CONTAINS IMPOR OCUMENT CAREFLLLY BEFORE SIGNING.IO
N T 1 HIS IS THIS
now of no 1' pe n who h a superior
MACON IS IRREVF.RSIB t a�We the full Il gal right and authority,an r
y warrant and represent '
I/We,the undersig(►ed,oert►f -warrant- processing and disposition of the remains of ame o ecease ` t,- P.M.g A.M.
priority right under state law,to authorize the cremation,p 0 t Time of Death '� _ �
(hereinafter refer#ed taps the"Deceased"). Date of Death ferred to as the "Funeral Home")to take
_ (hereinafter re
�j, CX� `KAN
thQtize ame o une ome
I/We hereby-re ."' f the Deceased at - ame o rematory
possession of and make arrangeme --------------
nts for remation of the r
(hereinafter refe►�Td �e".Crematory")• ossession and custody se the Funeral Home.
LL�� "Tim-;:` to return the cremated remains of the deceased to the p
I/We hereby ault�orize #iie' rematory
me to arrange for the disposition of the cremated remains of the
nd obligations of the Crematory shall be fulfilleod when the cremated remains of the deceased are returne to e
I/vie understan&4�alWgerAes a authorize the Funeral H
possession and cJJs1ody1rJA Aneral Home.VWe hereby
Deceased as follows: ,L J y �No Describe�lf►� J Yes - No
Is special
Ca',b M►, Suitable for shipping:
_ Cemetery
*r.^
Descriptioh of co11 �ets!le�cted.
����ame�55 ��
Deliver0 v
emr to ecerve remat emams
Releags4Vtmil
ame o stgnate amp y
Scattering at sea by Funeral Home or Funeral Home's agent
Ship via ilt S�4eg►stered Mall* Address
To:NanW._"
Other a of cremated remains shipped via Registered Mail with the United States
*Funeral Home and Crematory are not responsible for any loss or damag
postal Service. ains of the performed
ance with
The cremation,processing and di sitiand the
r m of the Crematory and Funeral Home,and the followng terms and conditio s:
all governing laws,the rules,regulationspoliciesthe 1. The remains of remaion container.The Crematory is authorted for ized to remove and di tion unless received b ose of handles,or amentsland any ther
resistant,rigid c
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,its agents and employees,to remove any such mechanical devices from the remains of the 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 ONTAIN 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 DisposWon
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 will be totally and
irreversibly destroyed by prolongedf 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 the remains of the beceased,may be destroyed during the cremation process. /We further authorize that it
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.
Q In the PVPnt fhP urn nr nnnfainPr is in—IFTI ant fn onnnmmn`Iotn n11 of thr ....—L...J .............. ..P LL.,T------
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