Mooney, Maurice r'_O WN OF QUEEN,5BU�KY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director �, �/g/J
Name dd/4� �C /p7d(j q AF y Case # a4 tl
Date of Cremation =/Q oYJ/
Time Cremation Started f 2 "g- /®.,Al
Time Cremation Completed rt MI
Type of Container D &X 15 ,00$:—
Remarks :
9Rim
nog t
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:
c�firt�-A
(Name) U (Sex)
�S GJ-
(Street) (City) I ( ate)-' (zip)
who died on 9 — day of 20 _
at
(Place) (Address)
Name and address of nearest relative or name of person Authorizing cremation:
(Na ) dd'ress,), 1� A
Relationship to the deceased��J'�""'l�
Name of Funeral Home
IMPORTANT:
I represent that to the best of my knowledge, the deceased has o has no p cemaker 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.
(Witness) (Address)
(Sig ture of Relative or Legal Rep.#fid Address))
Signed on this date: S �R i3 )
BEGAN R DEMY FUNERAL SERVICE
53 QWW Road
QuemsbWy,New York 12W4
(519)MI114
"Customer's Designation of Intentions"
�y Name of Deceased: ark,
Cremation: 1 lot ..,h.,►-._ ti_.)-,j
Scheduled Date) (Location)
. Manner of Disposition of Cremated.Remains:
❑ Burial at XReturn to Family
❑ Entombment at ❑ Other specify):
I hereby designate the Disposition of Cremated.Remains and acknowledge receipt of a copy of
this form.
(Signature)
(Printed Name) (Relationship to Deceased)
(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 N e of Funeral Director Signat of Funeral Director Date
or UndertAer 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 Malting Disposition Signature Date
#9 WHrM:Funeral Home Copy YELLOW:Family Copy PINK:Crematory Copy CUSINTEN Rev.Q96
X694M WESIAR GRAPHICS INC..(713)967.4676
AUTHORIZATION FOR CREMATION AND DISPDSIT,ION 031 Rev.4/98
NO�TI `E:THIS IS A LEGAL DOCUMENT.IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION.
CREMATION IS IRREVERSIBLE AND FINAL.READ THIS DOCUMENT CAREFULLY BEFORE SIGNING.
I/We,the undersigned,certify,warrant and represent that Uwe have the full legal right and authority,and noof no living person u rio
priority right under state law,to authorize the cremation,processing and dispositi n of t e remains of
(hereinafter referred to as the"Decea " A 76 ameo ece
to of Death �(J Time of Death A.M. - M.
I/We hereby request and authorize ,
ameo unera ome
hereinaft V
erred to as the "Funeral Home")to take
possession of and make arrangements for the re ation of the remains of Iteceased at ��(�t1t
(hereinafter referred to as the"Crematory"). Nameo 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.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 i- No Describe
Description of urn or container selected: Suitable for shipping: Yes -_ No
Deliver to Cemetery
ame an ress o eme ery
Release to family
Name o signate only MemGFr to Receive remate emams
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 radio ve device. In the event the remains of the Deceased contain such a device I/we hereby
authorize the Funeral Home,i ag and employees,to remove any such mechanical devices from the remains ofthe Deceased
prior to cremation, and dis ose h items at its discretion. I/WE HEREBY CERTIFY THAT THE REMAINS OF THE
DECEASED DO -_ DO NTAIN ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE.
Please initi one.
Listed below are all implanted h cal 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 Disposition
` Description of Implanted Device _ y 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 jewelry,and other personal
articles accompanying the remains of the beceased,may be destroyed during the cremation process.I/We 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 un entifiable consistency prior to placement in an urn or other container.