Usher, Timothy rrDWN 0F QUEE
,5BU KY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director � w
Name /c rye L jj- Case # �
Date of Cremation
Time Cremation Started r3/ A'm r
Time Cremation Comoleted Arm ,
Type of Container
Remarks :
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TOWN OF QUEENSBURY s
PINE VIEW CEMETERY& CREMATORIUM
G
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 t,
Rules and Regulations to Cremate the remains of:
(Name) (Sex)
�Sb , L�l LJ,1\
(Street) (City) St te) (zip)
who died on day of 20�_ \
at �`� � —��J
(Place) (Address) (�
Name and address of nearest relative or name of person Authorizing cremation: y
(Name) (Address)
Relationship to the deceased /L
Name of Funeral Home
e
i
it
IMPORTANT:
i
I represent that to the best of my knowledge, the deceased has has no 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 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)
(Signature of Relative or Legal Rep. and Address))
a�
l
Signed on this date: I � 1
r
., J
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
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 ki- -other authorized
person stating that they do have the power and authority to arrange for ,a 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 claim.. demands are,
or are not wholly groundless, false or fraudulent. This authorization in addition to a regular
burial permit must accompany the remains. j
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. befGr a the rei rains 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 thrr.ugh Friday.
Cremations done on Saturdays will be charged the additional $50.00.
Gl� ;
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1¢w AUTHORIZATION FOR CREMATION AN
FN(T CE:THIS IS A LEGAL DOCUMENT.IT CONTAINS IMPORTANT PRO D DISPOSITION
031 Rev.4/98
CREMATION IS IRREVERSIBLE AND FINAL.READ THIS DOCUMENTP S CONCER's*ING CREMATION.
I/We,the undersigned,certify,warrant and represent that Uwe have the full legal right and authority,and knoll CAREFULLY BEFORE SIGNING.
priority right under state law,to authorize the cremation,processing and disposition of the remains of of no living erson who has a superior
(hereinafter referred to as the"Deceased").
amen
Date of Death ( U l7 Time of Death �-(�
I/We hereby request and authorize a,,` - A.M. ,P.M.
ame o opera ome (hereinafter referred to as the "Funeral Home"1 to take
Possession of and make arrangements for the cremation of the remains of the Deceased at
(hereinafter referred to as the`Crematory").
ame o 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 returnee! to the
Possession and custody of the Funeral Home.I/We hereby authorize the Funeral Home to arrange for the disposition of the cremated remain.of the
Deceased as follows:
Is special handling required? Yes o gibe
Description of urn or container selected:
Deliver to Suitable for shipping: L Yes No
Release to family `L — ame an ress o eme ry Cemetery
Scattering at sea by Funeral Home or Funeral Home's agent o pate am,y em r to ecerve remate emams
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 shalt be pper firm a
all governing laws,the rules,regulations and policies of the Crematory and Funeral Home,and the following`terms aconditions:
h -
1. The remains of the Deceased will not be accepted for cremation unless received by the Crematory'in d combustible, 1-ak
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 ww�ftgnoornfbustible 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 la`v
manner it deems appropriate.
1. Mechanical or radioactive devices implanted in the remains of the Deceased (such as pacemakers,etc: m� create a hazard
when placed in the cremation chamber. The Crematory will not cremate any human remains-whieW-co nt ain 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,it and employees,to remove an yy such mechanical devices from the remains otzthe Deceased
prior to cremation, and disp a of sue items at its discretion. I/WE HEREBY CERTIFY THAT THE REMAINS OF TIIE
DECEASED DO _ DON AIN ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE.
Please initiar_eListed below are all implanted al 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
„6
Description of implanted Device Disposition
If no instruction for disposition is given,such items maybe disposed of at the discretion of the Funeral Home.= 'a
The cremation container containing the remains of the Deceased will be placed in the cremation--chamber and w%tbe totally
irreversibl destroyed by prolonged exposure to intense heat and direct flame.I/We authorize the Crematory fothe cremai,
chamber during b'pld the cremation process and reposition the remains of the Deceased in order to ffcilitate a"ip,& eaand thorough,"
cremation.
Certain items,including,but not limited to body prostheses,dentures,dental bridgework,dental fillipgs. ewelryyt pn8l ether personal
articles accompanying the remains of the beceased,may be destroyed during the cremation proCess:'I7e fiirfher 4ilthorize that if
any items, other than the cremated remains of the Deceased, are recovered from the cremation chamber,'they mby be separated
from the cremated remains of the Deceased and disposed of by the Crematory.
I/We hereby authorize the Crematory to separate and remove from the cremation chamber all noncombustible materials,inclpJi-919,
but not limited to,hinges,latches,nails,jewelry and precious metals,and to dispose of such materials. n ►. ,
i. Following cremation,the cremated remains of the Deceased,consisting primarily of bone fragments,will be mechanically pulyt �.
to an unidentifiable consistency prior to placement in an urn or other container. 4 - -
Unless an um or container suitable for shipment is purchased,the Crematory will place the crentatedremaiiisafihe Deceased it'a
container which is not designated for any type of shipment.
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(318)?02-1 I14
"Customer's Designation of Intentions"
Name of Deceased:
Cremation: �+ 1
� - Uj
(Schi uled Date) (Location)
Manner of Disposition of Cremated Remains:
❑ Burial at Return to Family
❑ Entombment at ❑ Other (specify):
I hereby designate the Disposition of Cremated.Remains and acknowledge receipt of a copy of
this form. -
r
r
(Si ature)
(Printed Name) }} (Relationship to Deceased)
( ess)
(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 Si ature of Funeral Director ate
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)
y (Date)
Name of Person Making Disposition Signature Date