Ramsey, Patricia rro WN OF QUEENB URY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director 6�i M I C/— / 1
I � `
Name J Case #
Date of Cremation
Time Cremation Started—?,t 4
Time Cremation Completed/ 1
Type of Container
Remarks :
91
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY&CREMATORIUM. �I
' 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:
(Name) (Sex)
(Street) (City) (State) (zip)
who died on day of Z20 b 1
at61 d
(Place) (Address)
Name and address of nearest relative or name of person Authorizing cremation:
Lm� - 12(
(Name) ( ddress)
Relationship to the deceased k u4z_ly
Name of Funeral Home a
IMPORTANT:
I represent that to the best of my knowledge, the deceased has o has 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
wholl dless, fa2le or fraudulent.
�e
(Wi ess) (Address)
(Signature of R ive or Legal Rep. and Address))
Signed on this date: �3
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 cremated remains is requested, check here
1
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 tt Friday.
Cremations done on Saturdays will be charged the additional$50.00.
a „
SULLIVAN-A+ Il"HAN POrrRit FiT L MONS
407 aw Road
Query,NY I2904
"Customer's Designation of Intentions"
Name of Deceased.: ra.. 'G x
Cremation•
(Scheduled Date) (Location)
Manner of Disposition of Cremated Remains:
Z Burial at ,��. r-1 If ;���►�..-,�,.., ��'..�>,.i El Return to Family
❑ Entombment at ❑ Other (specify):
I hereby designate the Disposition of Cremated.Remains and acknowledge receipt of a copy of
this form.
(Signature)
l�fi, rYt J iY� C f�°`1fG1S�i+Ti
(Printed Name) (Relationship to Deceased)
(Address)
-/ 7f,;- /91' ---
` ' (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 . fgnature,of Funeral Director Date
or Undertaker r' or Undertaker
l'
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'
VTEN Rev.4/96
#9 WHITE:Funeral Home Copy YELLOW:Family Copy PINK:Crematory Copy CUSIl
AND DISPOSITION 03IRev.4/98
AUTHORIZATION FOR CREMATION ORTANTROVISIONS CONCERNING CREMATION.
N 'fI'E:THIS IS A LEGAL DOCUMENT.IT CONTAINS
CREMATION IS IRREVERSIBLE AND FINAL.READ THIS DOCUMENT CAREFULLY BEFORE SIGNING.
s
I/We,the undersigned,certify,warrant and represent that Uwe have the full disposition of there gins ofan now of no living person w o has a superior
processing andame o ece
priority right under state law,to authorize toe cremation,p g _ A M PM
(hereinafter referred to s the"Deceased'). Date of Death /� O) Time of Death
_ p _ (hereinafter referred to s the "Funeral Home")to take
I/We hereby,request and authorize acne o unera Rome
possession of and make arrangements for the cremation of the remains of the Decease at
Name o rematory
(hereinafter referred to as the"Crematory").
to the possession and custody of the Funeral Home.
I/We hereby authorize the Crematory to return f the C ema ory shall be fulfilled e cremated remains of the ewhenthe cremated remains of the deceased are returned to he
I/We understand that the services and obligations of t
possession and custody of the Funeral Home.VWe hereby authorize the Funeral Home to arrange for the disposition of the cremated remains o the
Deceased as follows:
Is special handling required? _ Yes KNo Describe
Suitable for shipping: Yes No
Description of urn or
container selected: Cemetery
Deliver to .GL/ ame an ress o eme ery
17 Release to family
t emam
Scattering at sea by Funeral Home or Funeral Home's agent
=1 Ship via U.S.Registered Mail*
Address
To:Name
r' Other
*Funeral Home and Crematory are not responsible for any loss or damage of cremated remains shipped via Registered Mail with United States
the
Postal Service. ggains of the Deceased performed
ance with
The cremation,processrulesn edulations and policieis of the Crematory and Funeral Homel and the followng terms and reonditio s:
all governing laws,the g
1. The remains of the Deceased ion container.The Crematory is authorized to remove and di ill not be acceted for cremation unless received b ose of handles,ornamenty the Crematory in a s�andtible any otherresistant,rigid c
noncombustible items attached to the cremation container prior to cremation.In the event the remains of the Deceased are
or other n cb materials,
received y e is metal,in a casket or other container constructed of ble remation container.I/we authoiethe reman of the Deceased to be removed por to creman d placced in a combuti
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
In the event the remains of the Deceased contain such a device I/we hereby
implanted mechanical or radioactive device.
authorize the Funeral Home,its agents and employees,to remove an such mechanical ices from the remains of the Deceased
ical devices
THE REMAINS OF THE
prior to cremation, and dispose of uONTAIN ANY TYPE discretion.ch items at its
DECEASED DO DO NOTOF 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:
Disposition
Description of Implanted Device
Disposition
Description of Implanted Device
If no instruction for disposition is given,such items may be disposed of at the discretion of the Funeral Home.
3. The cremation container containingthe 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 Deceased,may be destroyed during the cremation process.I/I e further authorizehey may be that
if
any items,other than the cremated remains of the Deceased, are recovered from the cremation chamber,
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 theurn or C�oataPnnnda vinsufficient
ontainer andc a uirned to the Funeral Home,t getherowit a he pi ary urn or container.