Kantorski, Francis rT-o`wN OF QUEEN4,5BUWY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, -NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director/fr
Name 0�j�'f Case # J
Date of Cremation ado
Time Cremation Started rM !
1
Time Cremation Comoleted !
Type cf Container lJ(�C?� �( 02 /VV, C195,4-r
Remarks :
TOWN OF QUEENSBURY �I
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:
x
(Name) (Sex)
(Street) (City) (State) (zip)
who died on I day of 20 V I
at G����
(Place) J (Address)
Name and address of nearest relative or name of person Authorizing cremation:
(Name) (Address)
Relationship to the deceased
Name of Funeral Home
IMPORTANT:
I represent that to the best of my knowledge, the deceased has o s no pa emaker 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 j
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) (Addre s)
2L
(Sign ure of Relative or Legal Rep. and Address))
Signed on this date: )/I
I
Day
407 RW}.11IF
Que msbury,NY 12804
(518)793-4459
I r�
i
"Customer's Designation of Intentions"
bi4 ire of Deceased: r ;�, '� j i
Cremation ,' /f- l ��/ _`/%.`k. of h '�
'- (Scheduled Date) (Location)
`fs
9i
Manner of Disposition of Cremated Remains:
t r � e
❑ Burial at J ' ''`�• V l 5 ❑ Return to Family
❑ Entombment at ❑ Other (specify):
'ry
n4
I hereby designate the Disposition of Cremated.Remains and acknowledge receipt of a copy of
this form.
(Signature)
(printed Na e) (Relationship to Deceased)
( re/ss)j
(Telephone Number)
"Cremated. Remains which shall not have been claimed, within 120 clays from the date of31
cremation may be disposed of by this firm by placement in a columbarium."
Printed NarrA of Funeral Director Signs of Funer Director Date
or ndertaker r ndertalxer
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)
y
Name of Person Making Disposition Signature Date r
j
#9 WHITE:Funeral Home Copy YELLOW:Family Copy PINK:Crematory Copy CUSINTEN .4/96
031Rev.4/98
o ¢�, AUTHORIZATION FOR CREMATION AND DISPOSITION
NOTICE:THIS IS A LEGAL DOCUMENT.IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION.
CREMATION IS IRREVERSIBLE AND FINAL.READ THIS DOCUMENT CAREFULLY BEFORE SIGNING.
argI/We,the undersigned,certify,warrant and represent that I/we have the full legal right and authority,and know of no livperson ho h s a superior
priority right under state law,to authorize the cremation,processing and disposition of the remains of Name o eceaase t
(hereinafter referred to as the"Deceased"). Date f eat � �3 b/ Time of Death A.M. _, P.M.
1/We hereby_request and authorize d` (here�'�npft�er refe ed to as the "Funeral Home")to take
ame o unera in
possession of and make arrangements for the cremation of the remains of th eceased at Name of Crematory
(hereinafter referred to as the"Crematory").
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 Home to arrange for the disposition of the cremated remains of the
and custody of the Funeral Home.I/We hereby authorize the Fu
Deceased as follows:
Is special handling required? L Yes X No Describe
Description of urn or finer selected: Suitable for shipping: Yes
�-'�
l` Cemetery
Deliver to y ame an ress of Ceme ery
Release to family
ame o es�gnate amp y em er to ecerve remate emams
Scattering at sea by Funeral Home or Funeral Home's agent
Ship via U.S.Registered Mail*
To:Name Address
Other
*Funeral H11 m11 e11 and Crematory are not responsible for any loss or da mage of cremated remains shipped via Registered Mail with the United States
o
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.
ake disposition of any such noncombustible casket in any lawful
I/We further authorize the Funeral Home or Crematory to m
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 dispo items at its discretion. I/WE HEREBY CERTIFY THAT THE REMAINS OF THE
DECEASED DO : DO r o- � TAIN ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE.
Please ini 'al U.
Listed below are all implante nical and radioactive devices which the Funeral Home is authorized to remove from the j
remains of the Deceased prior to cremation,and dispose of as indicated: j
I
Description of Implanted 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 bls 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 thorougi►�
cremation. i
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 eceased,maybe destroyed during the cremation_-____ 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 pulverize
to an unidentifiable consistency prior to placement in an urn or other container.
7. Unless an urn or container suitable for shipment is purchased,thg Crematory will place the cremated remains of the Deceased in j
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 cremes q
remains will be placed in a secondary container and returned to the Funeral Home,together with the primary urn or container.]
__ ___n.L.al.,. —V .h►a earP%nd the nce of the Crematorv's best efforts,it l