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Loveland, Anne rro� � OF QUEENB U CRY PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEMNSBURY, '.v'EW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director F6: p( lv `� Name �/y/�I 1U �/9�VI� Case # 4�' LS61 Date of Cremation Time Cremation Started / /<T /41M I Time Cremation Comoleted l Type of Container 1.. 7P )(30x AINP, G v�Tl��" � Y Remarks : %s'y19 M T TOWN OF QUEENSBURY b©�j 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: 14»Y2e (Name) (Sex) / ) id,-L v�soh Jy�3rSi�w /a�Gmc L (Street) (City) (State) (zip) I who died on day of /U a V L .- 20 U 1 at Por - (Place) (Address) i Name and address of nearest relative or name of person Authorizing cremation: (Name) (Address) Relationship to the deceased -a k-3 H 4=r Name of Funeral Home IMPORTANT: -T .. :. I represent that to the best of my knowledge, the deceased has or has no pacemaker�iniis or her body. (Circle One) I certify that I have the full power and authorization to arrange For the cremation o thee!!�j ��d to direct the disposition of the cremated remains, that any personal possessions have eitfier"be kTeAved or may be destroyed, and agree to protect, defend and save harmless Pine View Crematoriu from any and.all claims and demands for loss or damages which may be made against,theWi'$¢ on f or connected with the cremation of said remains as directed, whether such claims or derrfands not wholly groundless, false or fr udulent. grime (Witness) (Address) l UJ )-V, CD (Signature of Relative or Legal Rep. and Address)) I Signed on this date: a) i REGAN & FENNY FUNERAL SERVIt;it Qumwbwy,New York 12804 (518)792-I114 "Customer's Designation of Intentions" Name of Deceased.: i=7.-r 7 r Cremation: (Scheduled Date) (Location) Manner off Disposition of Cremated. Remains: Burial at W t.+ e r r ro 1 L C rrz c i t ❑ Return to Family ❑ Entombment at ❑ Other (specify): I hereby designate the Disposition of Cremated Remains and acknowledge receipt of a copy of this form. Pi$nature) -�;�? .,.•) ,jam a�� �. , � f.. . .1 .- ). �.�_ (Printed Name) �� (Relationship to Deceased) (Address) (Telephone Numher) "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." i Printed Name of Funeral Director Si$natu of Funeral Director % Date or undertaker or Undertalzer TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF CREMATED REMAINS Cremation: (Actual Date) (Location of Crematory) -7 Disposition of Cremated. Remains: (Manner of Disposition) (Location) (Date) Signature Date Name of Person Making Disposition $ I #9 WHTTE:Funeral Home Copy YELLOW:Family Copy PINK:Crematory Copy CUSINTEN Rev.4/96 AUTHORIZATION FOR CREMATION A ND DISPOSITION N TI C :THIS IS A LEGAL DOCUMENT.IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION. 031Re�'a/vs CREMATION IS IRREVERSIBLE AND FINAL.READ THIS DOCUMENT CAREFULLY BEFORE SIGNING. UWe,the undersigned,certify,warrant and represent that Uwe have the full legal right and authority,and know of no livin priority right under state law,to authorize the cremation,processing and disposition of the remains of g Person who has a superior (hereinafter referred to as the"Deceased"). —ice P fame o ecease L ) v U j UWe hereby, Date of Death Time of Death request and authorize � A.M. '- P.M. t )p d a Possession of and make arrangements for a cremation of the remains of the Decease _ (hereinafter referred to as the "Funeral Home")to take (hereinafter referred to as the"Crematory"). 7 ,r.� ��r ame DF urematory 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.UWe hereby authorize the Funeral Home to arrange for the disposition of the cremated remains of the Deceased as follows: Is special handling required? Yes No Describe Description of urn or container selected: i7_ Deliver to Suitable for shipping: Yes --No r Release to family ame an ress o eme ery' Cemetery Scattering at sea by Funeral Home or Funeral Home's agent o s�gnat am,y em er to ecerve remate emams Ship via U.S.Registered Mail* To:Name Other Address *Funeral Home and Crematory are not responsible for any loss or damage of cremated remains shipped"'!via Postal Service. PP Registered Mai777!n 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 ofthe Deceased prior to cremation, and of such items at its discretion. I/WE HEREBY CERTIFY THAT THE REMAINS OF THE DECEASED DO _- NO CONTAIN ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE. Please 1 1 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 the, uugiB yQIne. +� 3. 'a a The cremation container containing the remains of the Deceased will be placed in,.the cr�at�on ch �gr aa� irreversibly destroyed by prolonged exposure to intense heat and direct flame.UWe%yy hIorizp the�i a a'CS� chamber during the cremation process and reposition the remains of the Deceased itt'order td fa�ilit4#i' I cremation. ' �6, I. Certain items,including but not limited to body prostheses,dentures,dental bridgework,dentnl'fillin , articles accompanying tote remains of the beceased,may be destroyed during the cremation process.I% a fui any items, other than the cremated remains of the Deceased, are recovered from the cremation chamber,th 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 noncombusti N n, ding, but not limited to,hinges,latches,nails,jewelry and precious metals,and to dispose of such materials. S. 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. 1. Unless an urn or container suitable for shipment is purchased,the Crematory will place_the.cremateA—rrglnains of the Deceased in a container which is not designated for any type of shipment. 3. 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 Drimary urn or container_ r