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Reis, Edward TOWN OF QUEEN, t5B URY PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director, /Y) t L-A, , ,�n� Name dg[2 1�l Case # ola, o Date of Cremation Time Cremation Started Az J'g'o P/ M t I Time Cremation Completed cqe0o )qi Type of Container J/FDr C'A9�,oiF ©/= 7h, Remarks : / /%mod f'•n>t , /�` Al TOWN OF QUEENSBURY PINE VIEW CEMETERY a CREMATORIUM Quaker Road, Queensbury, New York 12804 Phone (518) Crematorium 745-4477 or if 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: (Nave) 47 (Sex) (Street) L (City) (State) (Zip Code) who died on day of at (Place) (Address) Nacre and address of nearest living relative or name of person authorizing cremation: ame) (Address) Relationship to the deceased 21--eta Name of Funeral Home 6 nm IMPORTANT: epresent that to the best of my knowledge, the deceased or � or her body. (Circle One) ha�� pacemaker in his I-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, fals or fraudulent. (With (Acid re > (Signature df Relative r Legal Rep. and Address)/ Signed on this dates /h7 G� - DISPOSITION OF CREMATED REMAINS I hereby direct Pine View Crematorium to dispose of the cremated remains as follows : Mail to Other arrangements - please specify: If pulverization of cremate remains is requested, check here POLICIES, RULES AND REGULATIONS 1 . The crematorium will be open for cremations 5 days a week 7 : 00 A.M. - 3 : 30 P .M. Monday-Friday. No Holidays or Sundays, arrangements can be made for Saturday. Prearrangements by telephone for acceptance of remains is necessary. * 2 . Pine View Crematorium is located on the grounds of the Pine View Cemetery, Quaker Road, Town of Queensbury. 3 . An authorization for cremation properly signed by the nearest next of kin or other authorized person stating that they do have the power and authority 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 of damages which may be made against them by reason of or connected with the cremation of said remains and/or disposition of said remains as directed, whether such claims or demands are, or are not wholly groundless, false or fraudulent. This authorization in addition to a regular burial permit must accompany the remains . 4 . All remains must be encased in a casket or suitable alternate container. Caskets and containers must be of combustible material . No styrafoam or plastic containers will be accepted. 5 . The question relative to cardiac pacemakers must be answered on the authorization to cremate form before the remains will be accepted. 6 . Unless other arrangements are made the cremated remains will be mailed via Registered U. S . Mail within three days of cremation to the funeral home handling the service. There will be a $20. 00 charge for this service. Cremation, Administration Costs and Recording Fee: Adult $195.00 Children (age 13 months to 12 years) $115 .00 Infants (stillborn to 12 months ) $75 . 00 * Additional $50 . 00 charge for cremations done after 3 : 00 P.M. Monday through Friday. Cremations done on Saturdays will be charged the additional $50 . 00. L t (313) 2W "Customer's Designation of Intentions" �d a Name of Deceased.: rri Cremation: f ,.+:, t 1/.crr�r,• ,.y ;.� _� ,� (Scheduled Date) (Location) a. " Manner of Disposition of Cremated.Remains: ❑ Burial at ,Return to Family ❑ Entombment at ❑ Other (specify): I hereby designate the Disposition of Cremated.Remains and aclmowledge receipt of a Copy of tins form. (Sign tore) �i W„' (Printed Name) (Relationship to Deceased) (Address) ! 1 7 7 -7 6 ILZ (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 Director Date or Undertaker or Undertaker TO BE COMPLETED FOLLOWING CREMATION AND DISPOSMON OF CREMATED REMAINS Cremation: (Actual Date) (Location of Crematory) Disposition of Cremated Remains: (Manner of Disposition) (Location) (Date) 1 Name of Person Making Disposition Signature Date #9 WHITE:Funeral Home Copy YELLOW:Family Copy PINK:Crematory Copy CUSINI'EN Rev.4/96 031 Rev.4/98 oow�w AUTHORIZATION FOR CREMATION AND DISPOSITION b NQJICE:THIS IS A LEGAL DOCUMENT.I CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION. CREMATION IS IRREVERSIBLE AND INAL.READ THIS DOCUMENT CAREFULLY BEFORE SIGNING. I/We,the undersigned,certify,warrant and represent that I/ have the full legal right and authority,and know of no;iving pe!so�l who has a superior priority right under state law,to authorize the&emation,pr essing and disposition of the remains of Name o ece �/R y (hereinafter referred to as the"Deceased"). ate of Death `J�/Ak/ Time of Death ;C A.M. P.M. I/We hereby request and authorize - �atg,� hereinafter referred to as the "Funeral Home")to take me o uner ome possession of and make arrangements for the cremation of th remains of the Deceav Name of crematory (hereinafter referred to as the"Crematory"). I/We hereby authorize the Crematory to return the cr mated remains of the deceased to the possession and custody of the Funeral Home. I/We understand that the services and obligations of the C ematory 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? _ Yes XNo Descri Description of urn or container selected: Suitable for shipping: Yes - No Cemetery Deliver to _ ame not,moress o eme ery Release to family am e o gnated Family Member to Receive cremated Kemains Scattering at sea by Funeral Home or Funeral H me's agent - Ship via U.S.Registered Mail* To:Name Address f- Other *Funeral Home and Crematory are not responsible for a loss or damage of cremated remains shipped via Registered Mail with the United States Postal Service. The cremation,processing and disposition of the r mains of the Deceased authorized herein shall be performed in accordance with all governing laws,the rules,regulations and polic es 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 type of implanted mechanical or radioactive device In the event the remains of the Deceased contain such a device I/we hereby authorize the Euneral Home,its agents and a ployees,to remove any such mechanical devices from the remains of the Deceased prior to cre a ' T�1 dispose of such ite s at its discretion. I/WE HEREBY CERTIFY THAT THE REMAINS OF THE DECEASED DO 00 NOT CONTAI N ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE. Pleaseiinitial one. ted below are lanted mechanical and radioactive devices which the FuneratHome is authorized to remove from the e ains of the Decease prior to cremation,arid dispose of as indicated: M i escription of Implanted Device Disposition Description of Implanted Device Disposition If no instruction for disposition is given,such tems may be disposed of at the discretion of the Funeral Home. 3. The cremation container containing the rema ns of the Deceased will be placed in the cremation chamber and will be totally and irreversibly destroyed by prolonged exposure o intense heat and direct flame.I/We authorize the Crematory to open the cremation chamber during the cremation process and r osition the remains of the Deceased in order to facilitate a complete and thorough cremation. 4. Certain items,including,but not limited to bo y prostheses,dentures,dental bridgework,dental fillings jewelry,and other personal articles accompanying the remains of the�ec ased,may be destroyed during the cremation process.I/We further authorize that if any items,other than the cremated remains f the Deceased, are recovered from the cremation chamber,they may be separated from the cremated remains of the Deceased a d disposed of by the Crematory. 5. I/We hereby authorize the Crematory to sepai to and remove from the cremation chamber all noncombustible materials,including, but not limited to,hinges,latches,nails,jewey and precious metals,and to dispose of such materials. 6. Following cremation,the cremated remains ohe Deceased,consisting primarily of bone fragments,will be mechanically pulverized to an unidentifiable consistency prior to placent in an urn or other container. 7. Unless an urn or container suitable for shipmt is purchased,the Crematory will place the cremated remains of the Deceased in a container which is not designated for any tyof shipment. 8. In the event the urn or container is insufficie to accommodate all of the cremated remains of the Deceased,any excess cremated remains will be placed in a secondary contairand returned to the Funeral Home,together with the primary urn or container. n 7iX:7___�J..__..a.___a .__a ..a,..,...,1,..�,.,, se.n♦,..,.,. ,;ah#16— f tha Pramatnrvlc hact affnrtc 4 is