Ridley, Robert rrD O� 21 �%5BU. Y
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PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, 'NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director i
Name LoLF9 / Case #
Date of Cremation
Time Cremation Started �91 M )
Time Cremation Completed
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Type c_` Container ��(�
Remarks :
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TOWN OF QUEENSBURY �31
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:
120 bcr--f -1�4 d 6 n7k
(Name) (Sex)
(
✓ Gi PiI
(Street) (City) (State) (zip)
who died on f3 day of /� D�y 20��
at
G os
(Place) (Address)
Name and address of nearest relative or name of person Authorizing cremation:
eljcj---� k(ri1fd4
(Name) (Address)
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Relationship to the deceased
I
Name of Funeral Hom��J 1 V�— G C►.
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IMPORTANT: j
i
I represent that to the best of my knowledge, the deceased has r has 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
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 fr ulent.
I
(Witness (Address)
(Signature of Relative or Wagal Rep. and Address))
I
Signed on this date: 1
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I
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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 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 gncased 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.
G-Z,. 031Rev.4/98
� TI
o�v AUTHORIZATION FOR CREMATION AND DISPOSITIO
b <`�
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,and of no living pe who has a superior
priority right under state law,to authorize the cremation,processing and disposition of the remains of Name otileceaseu
(hereinafter referred to as the"Deceased")• Date o Time of Death A.M. P M.
f Death b
((hereinafter referred to as the "Funeral Home")to take
I/We hereby request and authorize
e o unera ome
possession of and make arrangements for the cremation of the remains of the Deceased at t ame o ematory
(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.
services and obligations of the Crematory shall be fulfilled when the cremated remains of the deceased are returned to the
I/We understand that thethe Funeral Home.I/We hereby authorize the Funeral Home to arrange for the disposition of the cremated remains of the
possession and custody
Deceased as follows:
Is special handling required? Yes -1<
No Describe
Suitable for shipping: ': Yes No
Description of urn container selected: Cemetery
Deliver to r5( ame ana Address of Cemetery
Release to family ame o es�gna amp y em r to ecewe remat ,mains
Scattering at sea by Funeral Home or Funeral Home's agent
Ship via U.S.Registered Mail*
Address
To:Name
I
Other
* Home and Crematory are not responsible for any loss or d an of cremated remains shipped via Registered Mail with the United States
Funeral
Postal Service. gg
The cremation,proce rulesnedulations and policies of the Crematory and Funeral Homains of the Deceased authorized e a d the following terms and conditio sance h
all governing laws,theg in a
I. The remains of remltion container.The Crematted for ory is authorized to remove and di tion unless received by se of handles,�ornamentsl and tany thee{
resistant,ri ar
gidation. In the
noncombustible
Crematory attached a casket crema r they container co tion container nstructed of metal,fiberglass,or other noncombustible materials;
received
c in a combustible ii
I/weauthorize remains Deceased
removed
non of any such noncombustible casket in any lawful
unerHome or Crematory dsposit
I/Wef further authorize the F
manner it deems appropriate. i the remains of the pp
2. Mechanicalaced in the cremation chamber. The iin em itory will not cremate any humch asan remains swh ch contain any type d
when plbl
aced
hmechanical or e Funeral Home,t s ageve is andlce. In the event the ee, I/we here
mployees to remove an such mechanical cal devices from the remains a nscof the Decea ej
authorize t yy�
prior i cremation, and Home,
its h items at its discretion. I/WE HEREBY CERTIFY THAT THE REMAINS OF T
DECEASED DO DON NTAIN ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DEVICI
Please initi 1 o e.
Listed below are all implanted anical and radioactive devices which the Funeral Home is aulffid`ied to remove from t�
remains of the Deceased prior to cremation,and dispose of as indicated:
Disposition
Description or Implanted Device
Disposition
Description or 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 containing the remains of the Deceased will be placed in the cremation chamber:r
irreversibly destroyed by prolonged exposure to intense heat and direct flame.I/We authorize the Crematory 4r�l���
chamber during the cremation process and reposition the remains of the Deceased in order to facilitate a c: "'S� P',
cremation.
4. Certain items,including,but not limited to body prostheses,dentures,dental bridgework,dental fillings jewels , >pallya�
articles accompanying the remains of the beceased,may be destroyed during the cremation process.We further fi th matz y
any items, other than the cremated remains of the Deceased, are recovered from the cremation chamber,they m€ °roUg
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,it,but
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 mechapically pulvQ
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 arty Deceased
container which is not designated for any type of shipment. T
8. In the event the urn or container is insufficient to accommodate all of the cremated remains of the Deceased,any exec crem
remains will be placed in a secondary container and returned to the Funeral Home,together with the primary urn or tbutai
�l AOgr Rt�rd
Qaoaubuo%NY 12804 ,-
(5I8)792-2067
"Customer's Designation of Intentions"
Name of Deceased.: "' �. !' c
Cremation: (j(_i
(Scheduled Date) (Location) _'� ;
Manner of Dis ition of Cremated.Remains: x .•r .'
' Burial at^ I f'1E'.:V KW ❑ Return to Family
•'a 1G4
❑ Entombment at ❑ Other (specify): ' n;
I hereby designate the Disposition of Cremated.Remains and acknowledge receipt of adcopy o
this form.
(Signature).,
�— (cl—I 6,t ! fie•
(Printed Name) (Relationslnp to Deceased)
^t-
(Address)
its
SG-
(Telephone Number)
"Cremated Remains which shall not have been claimed. within 120 days from the date Te _
cremation may be disposed of by this firm by placement in a columbarium."
Printed Name of Funeral Director Signor a of Funeral Director bate i Y»or Undertaker or Undertaker 4'fi? vj= {±F
TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF CREMAT%RE
Cremation:
(Actual Date) (Location of Crematory) z,1
Disposition of Cremated Remains:
(Manner of Disposition)
- i
(Location)
(Date)
Name of Person Making Disposition Signature Date
#9 WHITE:Funeral Home Copy YELLOW:Family Copy PINK:Crematory Copy CUSINTEN Rev.4/96