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Brown, Russell , ' rnWN OF QUEENBU1 Ky PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEEINSBURY, :,EW YORK 12804 (518) 745-4476 (518) 745-4477 �ii Funeral Director �j,1�,(,I��Z Name 416, : �,L.�, ,� ��/Y Case # / Date of Cremation " Time Cremation Started Time Cremation Completed a21'3& Type cf Container Remarks : 1 164 r a% ,l� P.rns e TOWN OF QUEENSBURY PINE VIEW CEMETERY CREMATORIUM / Quaker Road, Queensbury. New York 12804 / Phone (518) Crematorium 745-4477 (if no answer) Cemetery 745-44.76 AUTHORIZATION TO CREMATE The undersigned requests and authorizes Pine View Crematorium. in accordance with and subject t2s Rules and Regulations to crema the remains of: U.SS-g-S�21s � (NA E) (SEX) (STREET) (CITY) (STATE) (ZIP ODE) �� � � 6 who died on dayof 20� at (PLACE) (ADDRESS) Name and address of arest living PL�� re or nam of person authorizing cremation: i �� �u� ' Ry Relationship to deceased &7915 Name of Funeral Home IMPORTANT I represent that to the best of my knowledge, the deceased has or as no) o acemaker 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 a aI them bJXeason of or connected with the cremation of said remains as directed, whether s h claims or ehiands are or re n t wholly groundless, f Ise or fra ulent. (WITNESS) (AD E S) (SIGNATURE OF R LA T VE OR LEGAL REP. AND ADDRESS) Signed on this date: �� � l DISPOSITION OF CREMATED REMAINS I hereby direct Pine View Crematorium to dispose of the cremated remains as follows: Mail to ements- leases ecify: AL Other arrang p P If pulverization of cremated 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. Pre-arrangements 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 or 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 Styrofoam 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 $25.00 charge for this service. Cremation, Administration Costs and Recording Fee: Adult$300.00 Children (age 13 months to 12 years) $150.00 Infants (stillborn to 12 months) $100.00 * 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. SINGL 'ON-E "X FUNtRAL BOMB 407 d Qu buq,NY 12804 (519)7934459 "Customer's Designation of Intentions" 1 Name of Deceased.: Cremation: I 1:50 AA/,•�l�'� d D d(Scheuleate) (Location) Manner of Disposition of Cremated Remains: 14 Burial at Return to Family ❑ Entomhment at ❑ Other (specify): I hereby designate the Disposition of Cremated.Remains and acknowledge receipt of a copy of this form. (Si afore) fro 7A k (Printed Nam , (Relationship to Deceased) V, (Telephone Numher) "Cremated. Remains which shall not have been claimed. within 120 days from the date of c emation ma be dispose4 of by t firm b lacement • a lumbariu ." Printed Name of Funeral Director Signature of 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 WHPfE:Funeral Home Cop' YELLOW:Family Copy PINK:Crematory Copy CUSINTEN Rev.9✓96. o 0 1 AUTHORIZATION FOR CREMATION AND DISPOSITION 031Rev.4/98 N 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,ao kn w f 1' in erson priority right under state law,to authorize the cremation,processing and disposition of the remains of =� supe io (hereinafter referred to as the"Deceased"). Q �� � Date D / �I ease � Time of Death r A.M. I/We hereby request and authorize �,d (hereinafterr to "Funeral Ho " to take possession of and make arrangements for the cremation of the remains of the Deceased at (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 E)ko Describe Description of urn or container selected: Suitable for shipping: Yes No Deliver to y Cemetery ame an ss o eme ery Release to famil ame o s�gnate amp y em r to ecewe remat emams -i 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 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 &CONTAIN 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 Disposition Description of Implanted Device Disposition If no instruction for disposition is given,such items may be disposed-of at the discretion of t wFuneral-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.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 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. S. 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.