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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 'M r /J r ® � ,& 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.