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Meyer, Walter rro(KN OF QUEENB U WY PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director Name 4M/'TE'lz /� ��' Case # oZ3g Date of Cremation Time Cremation Started Time Cremation Completed I'm j9i/11Z ( Type of Container j, � X /�� �G/ �o� 7, (4F- Jay T Remarks : /09/ �h <�/9/n� c �� 1$ 19 "MI � r � I 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: LULL )T_r� I'Y>r v1 (Name) (Sex) LA- rr C� kYJ :,r7 t- At a 1\0 Y (Street) (City) CJ (State) (zip) who died on n�{ day of 20 0) at i )rs}:✓n0Un� �cC,>f4 �acam. bi" (Place) (Address) Name `and address of nearest relative or name of person Authorizing cremation: l W) 1 k rA YYf YV7 P Yt-L y (Name) ddress) Relationship to the deceased Name of Funeral Home r� E, 7 e�.� .�r,- 1 W a,r+, sr e- r 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 fr ulent. ff--=2 D, (Witne (Address) igna ure of Relative or Legal Rep. and Address)) Signed on this date: t),/:2 ?f cl r BAN&DENNY FUNIRAL SERVICE F 53 QWW Rood Qw=*W)%Now Yat 12304 (518)792,1114 _ r "Customer's Designation of Intentions" Name of Deceased.: I-Ai fA ) t t r Y-7-2r 14 vt Cremation: 9 ),2_3 0 J )/7 r i f e cis La C , r : C, _c (Scheduled Date) (Location) Manner of Disposition of Cremated.Remains: X 4jr Burial at t r., I z C,u,t c^r y?c C r v,, ,r L k s- ❑ Return to Family ❑ Entombment at ❑ Other (specify): I hereby designate the Disposition of Cremated.Remains and acknowledge receipt of a copy of this form. (Sature) g FF ` LA—)) iin ,�'1 77C"urr (Printed Name) / (Relationship to Deceased.) (Address) }1 ! CA SaV3 - (Wephone Numher) "Cremated. Remains which shall not have been claimed. within 120 days from the elate of Cremation may be disposed of by this firm by placement i a Columbarium." 0 Printed Name of Funeral Director Signature 6T Funeral Director Date 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) Name of Person Making Disposition Signature Date #9 WHITE:Funeral Home Copy YELLOW:Family Copy PINK:Crematory Copy CUSINTEN Rev.4/96 + i n. wi i� utJ a.�� .✓rn i� LVO ..Y :J..•OJ f V 7LJ 1D f 7L1co( r.Ce"U-) V � gvvq' M.v qq vim.. �r +r... . ..v •• M✓..•... II�V�../ 1 r•V4 V� .?�~ ALTTHOR�ZATION FOR CREMATION Ah'� DXSPOSITION . ---- �,��.•� j�Qjj ';:1'tltS t3 A LtitiAt�UUCU�tIEN'!;I't't:t)N7'A[NS IMl+On7'A1V7'PROVISIVNS CONC4RNlNlC CRF.MATtON• L'RlrMhC1UN IS 11tRl:YtvR511LLl.tt ANn FtNAL.1tI:AD rH1$ual.:uML�NI'CA.1il8J�ULtrX sEFOitE 51t+NWG. lWe,tltt undersigned.earthy,warrant and rspresenl tttet 11wo have the full Iegal right sued authority,and know of no llvin;person who has a s�tVertpr irlority right under"to lawf to authorize the cremation,processing and dispostIt of the Mine oP, j,��fit*• hereinafter referred to as the"Deceased"). of Dtath Z me (i A.lt. L I P.M. Date ofDcath ! Ti ���' VWe berth,request and authorize (here rafter referred Was the"Fun"point")to take wasesslon of and maize surnngemencw fbr the axamation ef the remains or the Deceased at roses►"r-- hetelitatter referred to as the"Createtory"). VWe hereby authoritt the Crematory to return the crtrgnttd ranains of the deaeated to the possession and cust9dy or the Funeral home. Me understand civet the services and obl'fgatlons or tilt Crtinatory shalt be fiitfilled when the cremated remains of the deceased am returned W the Possession and custudy or the truaeral Home.I/We hereby authorise the Fu4lral home to orrsl,e for the dlspa+ilion of the cremated reMalae or the Deceased as follows: laspKWhwWlinZnquArad7 0 YesXNo Describe. - Description of tires or container selected: _ Suitable for shipping: Q 1e: ONO 0 Uelivcr Ce► to ---- - -_--- ,tetery i ltelebl�ll'tlb titlibilr w f , t r. aiTcd f..au.r I 1 Sc1411C1.4%nt st-t Oy trunarut ilun►e or Nulleml Iluu►ck Avent ( t ship via U S.Registered Malt• 7b:Now - Adilrew V Other _ • ttiteral Drat end CrinnaroRry art n4 respoasime for any loss or ersn+atp remZG shipped via Reg' ed Uwith we Vtute4 hies _Poster Service. __. �• the cremation,processing and disposition of the remains of the Deceased authorized bereln shall be pertirrmtd is accordance with all governing tarns,the runes,regulations and policies of the Crematory and Funeral Home,and the r9 lowing terms and coeditionst 1. Th remains of the Uectased will not be accepted for cremation'unlew received by the Crematory in a combustible, leak res�stant,rlfgid cremation container.The Crematory Is authorized to remove and dispose of handles,orenaracids and any other nonc4ombustible Items attached to the cremation container prior to cremation.In the event the remains of the Deceased are rer-atwed by the Crematory in a casket or other container eol}stmcted of metal,fiberglass,or other noncombustible materials, I/eve authorize the remains of the Deceased to bo removed prior to cremation And placed in a combustible cremation container. Me further authorize the Funeral Notue or Crematory to make disposition of any such noncombustible casket in any lawful manner it deetits apptoprtate. �. Mechanical or radioactive devices implanted in the remains of the Daceas4d (such as paceinaktrs,@te.)may create a hazard when placed is the cremation chamber. The Crematory will not c tan a an human remains wbich contain any type of Impplanted mechanlcal or radioactive device. In the event the rt:ma less o�the &sod contain Stich is device Uwe hereby auttlorize the FnaeW Hon agents and employeese to reMOVt an�r sech tnecbatticai devices in the remains lyttthe Deceased prior to cremation, sad isp 1 items at its discretion.I/WE Ci1�RE8Y CERTIFY T '��'l+t REMAINS OF xHly DECEASED DO 2 O NOT ONTAIN ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE. lnea3�. Listed below-are all implanted mechanical and radioactive devices wbich the Funeral Platte is authorized to remove from the remains of the Deceased prior to cremation,sad dispose of as indicated: av+ftrdm.tdsrw�f•t,oatw al,t�feMMe 9wvt,uon gfheo w a.ries If no instruction for:disposition it given,auch items may be disposed of at the discretion of the Funeral Home. 3. The cremation container eoatalumui qg the remains or the Deceased will be placed in the cremation chamber and Will be totally mad Irreversibly destroyed by prolonged exposure to intense beat aad direct flatus.I/We authorize the Crematory to open thg cremation chamber during the cremation process and reposition the rmalux of the Deceased In order to fadlitate a complete and thorough cremation. 0. Certain items,including but not limited to body prostheses,dentures,dental bridgework,dental filua Jewelry,and other personal ardeles accompanying Is rev ai,as of tit#becessed,may be dewoyed dorlog the Cremation yroceaIN't rvrtber authorize that If as me,other t�d the ciremated remains or the are recovered from the creme oft n chamber,they may be separated from he cryemated remain of the Deceased and disposed �y the Crematory. 3. but soot limited to,,authorize the la c a,Rills separate eewwei y and precioti meullss a d w tdispose of su h noncombustible r+>aterials,including, 6. FolloTrin eseniatlon,the cremated remains of the Deceased,eorlmistin primuriiy of bone fragments,will be mechanically pulverized to an urd entiflable consistency prior to placement in art 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 wWch is not designated for any type of sbipment. d. In the event the urn or container is insuMcient to accommodate act of the cremated remains of the Deceased,any excess cremated remains-rill be placed in a secondary container and returned to the Funeral Nome,together with the primary urn or container. 9. Mo smOrs;tand and aeknowittl tlZat even with the exercise of reasomable care and the use of the Crematory's;best efforts,it is Cr APR 24 20a1 09:29 518 792 1287 nrr� cti CGGi i l•4J f-t1: LX:,; J GU L-nC 1 VHNU eud 5•S ''J l— I!; J1 11d'e,1c1,:UY !1.PJIJI,ut, I>I,,.aglr. W wMlnr et tA/14Nc!Ls•la It no instruction for disposition is given,such itein:4 inay be disposed ii of at the dtscretioo of tlse� lter oma n chamber 1. The cremation t o li pralungled exposure ats intense l�etat and direct ftd will bearne�ed in be lUWe and authorize the 4rtmator ato owsn he,ill be cremation ellamer d destroyed Y - chamber during the rtoirwtion process and reposition lice remain::of the Deceased in order to facilitate a�,omp to and thorough cremation. ,and other ersonal rostbeses,dentarea,dental►ridge`ark dental fiHto e' ry, p 4. Certain items,ineiudia$ but trot limited to.body p be se crated articles accompattYyiit, ,b rtmttins of the Deceased, Deceased,are i cco a ted$fxhoM the cremation Cheltnacr,the�ttnaYtbe so that d etly items, otber chop the<remated remains o from Thee cbr�emated retrains of the Deceased and disposed of by the Cretna(ory: 5. b�ndt liuuiied tu�1 rases WtCbees,nails,jewelry send preciotu3 eriettals.ahe ndrto dispose o suchlmater4ts S.bhbk�terilly per including. 6. Foltowin ere ttoa,the cremated reirle.ias of she Deceased.consisting pritnarily of bons frstgmtnts,will be mechanically p utverised to ao un5ont le consistency prior to placement in an urn or other container. 7, 1lnies9 an urn or container suitable for ShIPmenct�shPurchased, the Crematory will place the cremated remaias of the Deceased in a container which iS not designated for any type ip S. In the event the urn or container is insuftieient to acc4la11119 itoall of the cremated ogether with iith he pritn+��y any orrconttaai;ner.� rerylains.�+ill be plaked in a secondary container and returned to the ptinenai dame, is 9. I/ a iLad er tond and r,�ll p led C,that the cremated r with theemoliu of thr Deiti ectl,cad ttLat s�rne oartdcles ineGsaykiradvea teare�obeC�otr e comtpttir ed with particles of other cremated xenauins ramainln is he of ainy such reeslduallor particlethers In Say JaWful rraprocess n Kt the cremated reinaiss. )L'We hereby .authorize the Crentatury o dispose Y deems appropriate ip, U anti;X/wr.ttive specitie written instructions in skis Authorization,tiles cremathoub orion p o ce staug�nd dispositic"of the rrtnaina© t e Deceased wilt not be performed 1n accordance with any par S 11. In ttie event the cremated retrains of the Deceased remain unclaimed for a period of 30 days,the FuneraleHorne at shu11 guru of the nDecEssed ones usn anclr certified for a period of l e ys lattel ti a data alud'i wr!ten notification istime'ad the Funeral Home is outhorired and directed to dispose of t�ie_uodaitrcd ereuuated remaias of the Deceased in any tawllul toaniier it may deem appropritue. 12, I/We agree to indenwif'!',release and liold the Crematory,Funeral Home,their affMates agents,ens toy'ees and assigns,harmless from any and all loss,dat»aig�,liability or causes of action(iricludin attars:eys'feet as expanses libgatlan)in eo»ttey Id with the cremation and disposition of the cremated remains of the Decease,as authorized keraw,or,nnylour fedure to cyrrectty identify the rgnaiat of the Deceased,disclose the plMseuce of an implanted mechanical or radioactive devices, or take posseeaslor of,or make permanent arrangements for,the deposition of such retrains. 13, zcept as act forth in this Aotborization,no warranties,expremed cr implied,are made by the Funeral linme,Crematory,or any of l their respective afliliatts,agents,or employees. +' process. 14. VWe underst1g�a that this docillnent doe not Contain a complete and detailed desc iption of ever a►s, act of the cremation VWe acknowledge receiving, from the liuneral Heine, a copy of the booklet entitled Crematton 'acts" toyttaLning additional txptaustory information about the cremation process- SIGNATURE OF PERSONS)AUTHORIZING CREMATION AND OISPOSMON i1Vr'e warrant that d1 reprtuutatiors anti ttatwents ins►de herein are true and correct,and (brit Vwe have read and understand the provisions coateived le,this document,and that Vwe have received the booklet eatltltd"Cremation�at swish" nM Address L r...>` NOW eoc of M aAS ALP. t?KNiltl Addrea WITNESS l - Date: •�—�sl Ptml O teYB Manepsms,,t L.P. 1 MM! Qam""Cap YULawa h,eawy copy rm-f ht*ibvA Cap GCW,►"i,Cerr A�h 0 /�. lll4ry a 't_ 3 YYt tar:I�<•.ewl L..� C.✓.c el tSa►:�... ,� F.t��6 APR 24 2001. 05:321 51a 792 av PRGE,M o�4w AUTHORIZATION FOR CREMATION AND DISPOSITION 031 Rev.4/98 NOTICE:THIS IS A LEGAL DOCUMENT.IT CONTAINS IMPORTANT PROVISIONS COWERNING CREMATION. CREMATION IS IRREVERSIBLE AND FINAL.READ THIS DOCUMENT CAREFULLY BEFORE,SIGNING. I/We,the undersigned,certify,warrant and represent that I/we 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 ( U a 1 .d-, yYaeu e. ame o ecease (hereinafter referred to as the"Deceased"). Date of Death L) 1,22) p) Time of Death 7 A.M. P.M. I/We hereby request and authorize Rea D�» -�t�e»►-s�, 'ry r,e.�J 11�0>�o (hereinafter referred to as the "Funeral Home")to take —0- am imera Home possession of and make arrangements for the cremation of the remains of the Deceased at Pi n r V'r.�) (hereinafter referred to as the"Crematory"). Name o rematory 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.UWe 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 Describe Description of urn or container selected: Suitable for shipping: Yes No Deliver to Cemetery ame anAddress of Cemetery 1-1 Release to family ame o �gna amp y em r to ecewe remate emains - Scattering at sea by Funeral Home or Funeral Home's agent 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 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 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 Funeral Hom agents and employees,to remove any such mechanical devices from the remains of the Deceased prior to cremation, an�*ti h items at Its discretion. I/WE HEREBY CERTIFY THAT THE REMAINS OF THE DECEASED DO NTAIN ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE. Plea - 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 Impianted 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 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 the remains of the beceased,may be destroyed during the cremation process.Ile 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. q_ I/We understand and acknowledge,that even with the exercise of reasonable care and the use of the Crematory's best efforts,it is _