Latronica, Wayne rro UN OF QUEEMB URY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name cJ� /�l� ,C, i9r/;�3nlG!f4 Case #
Date or Cremation
Time Cremation Started
Time Cremation Comoleted
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TOWN OF QUEENSBURY
4 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:
L La2otV;c�A 1`rtLlr
(Name) (Sex)
�1 %/luck Vt5 12 State) �\lY•(ZiP)
(Street) (Cit y)
who died on
' I day of nla�`�1�r a 20 d f<
at
llZa�L-12i 5 i • I
(Place) (Address)
Name and address of nearest relative or name of person Authorizing cremation:
(Name) (Address)
Relationship to the deceasedV�
Name of Funeral Home /ZG GArJ `C �� �V
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or has no 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
save harmless
or may be destroyed, and agree to protect, defend and mless Pine View Crematorium from any
or
and all claims and demands for Ioss or damages which may b
remains as
connected with the cremation of saiddirected, whether such claims e made lor demands are nst them by aor are son fnot
wholly groundless, false or fraudulent.
(Witness) (Address)
i
(Signature of Relative or Legal Rep. and Address))
Signed on this date: J�XXIo
': •��'" Q .`/=New Ywk 12WA
£. (5I8)'792-1 t 14 .
' "Customer's Designation of Intentions
..sue
Name of Deceased: 1 i
1
:: Crematiouv- �� l�s
(Scheduled Date) (Location)
t
f Disposition of Cremated.Remains:
Manner o
4 f;
❑ Burial at C9 Return to Family
El Entombment at
El Other (specify):
I hereby designate the Disposition of Cremated.Remains and acknowledge receipt of a copy of
'tthis form. "`a
fiignature)
(Printed Name)
(Relationship to Deceased) j
(Address) I
(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."
Printed Name of Funeral Director gignature of Funeral Director,', Date
or Undertaker or Undertaker j
- I
TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF CREMATED REMAINS
I
Cremation:
(Actual Date) (Location of Crematory)
Disposition of Cremated.Remains: j
(Manner of Disposition)
I
(Location)
I
(Date)
I
Signature Date
Name of Person Making Disposition si g
Cremato Co CUSINTEN Rev.4/96
#9 WRITE:Funeral Home Copy YELLOW:Family Copy PINK ry PY
Y� r
AUTHORIZATION FOR CREMATION AND DISPOSITION 03IRev.4/98
:THIS IS A LEGAL DOCUMENT.IT CONTAINS IMPORTANT PROVISIONS CONWERNING CREMATION.
M A' ,N IS IRREVERSIBLE AND FINAL.READ THIS DOCUMENT CAREFULLY BEFORE SIGNING.
I/We,the undersigned,certi(kj*arrant and represent that Vwe have the full legal right and authority,and know of no living person who has a superior
priority right of.der state law,to authorize the cremation,processing and disposition of the remains of WAU A 1 J t4 4 G
or
(hereinafter referred to as the"Deceased"). Nrmsea�
Date of Death.`A d Time of Death A.M. P.M.
I/We hereby request and authorize �GCo 1� L-)g `a � (hereinafter referred to as the "Funeral Home")to take
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�oi runera Home _
possession of and make arrangements for the cremation of the remains of the Deceased at 101de" W e k z
(hereinafter referred to as the"Crematory")- ame o 're atory
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.I/We hereby authorize the Funeral Home to arrange for the disposition of the cremated remains of the
Deceased as follows:
Is special handling required? - Yes A,No Describe
Description of urn or container selected: Suitable for shipping: Yes No
❑ Deliver to Cemetery
_ r nn �,,�� ame an Address o cemetery
Release to family S i-C� C Kati
Name oDesignateami y Member to Receive Cremated Remains
Scattering at sea by Funeral Home or Funeral Home's agent
- 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 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 of the Deceased
prior to cremation, and dispose of such items at its discretion. I/WE HEREBY CERTIFY THAT THE REMAINS OF THE
DECEASED DO - DO NOT XCONTAIN ANY TYPE OF 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:
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 Funeral Home.
3. The cremation container containing the remains of the Deceased will be placed in the cremation chamber and will be totally and
irrever$i I .destroyed by prolonged exposure to intense heat and direct flame.I/We authorize the Crematory to open the cremation
charting the cremation process and reposition the remains of the Deceased in order to facilitate a complete and thorough
crenphotiE:
4. Cert items,including but not limited to body prostheses,dentures,dental bridgework,dental fillings a Mry,and other personal
artic accompanying the remains of the beceased,may be destroyed during the cremation process.I/ a further authorize that if
an ins other than the cremated remains of the Deceased,are recovered from the cremation chamber,they may be separated
fro Fie cremated remains of the Deceased and disposed of by the Crematory.
5. I/We%rebT authorize the Crematory to separate and remove from the cremation chamber all noncombustible materials,including,
but 4oC invited to,hinges,latches,nails,jewelry and precious metals,and to dispose of such materials.
6. Following cremation,the cremated remains of the Deceased,consisting primarily of bone fragments,will be mechanically pulverized
to aride_ntifiable consistency prior to placement in an urn or other container.
7. Unless$[ri, _ -4r container suitable for shipment is purchased,the Crematory will place the cremated remains of the Deceased in a
cont - er„which is not designated for any type of shipment.
8. In the'tevenf 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 primary urn or container.
9. I/WJunde`rstand and acknowledge,that even with the exercise of reasonable care and the use of the Crematory's best efforts,it is