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Phillips, Lillian . rrnWN OF" QUEEN ,5B U. KY PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director `j,/ Iyex f,,�- ky, Name ,� ��/�� �/y p�jW, 10 Case # 6/6 Date or Cremation Time Cremation Started 4 • ICO /9" M ' Time Cremation Completed M f Type cf Container /Cyr' IVY "y Remarks : /M i i i i i e _ TOWN OF QUEENSBURY PINE VIEW CEMETERY ` CREMATORIUM Quaker Road, Queensbury, New York 12804 Phone (518) Crematorium 745-4477 (if 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) Vcl . C a�-o (STREET) ( ) (STATE) (ZIP CODE) who died on ` day ofIAX�L 20 O�;L at ks'(-_ I (PLACE) (ADDRESS) i Name and address of nearest living relative or name of person authorizing cremation: I Relationship to deceased S i Name of Funeral Home �- i IMPORTANT I represent that to the best of my knowledge, the deceased hasedmation cemaker in his or her body. (CIRCLE ONE) I certify that I have the full power and authorization to arrange f 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. ( TNESS) (ADD S) YX (SI N F URE OF RELATIVL OR LEGAL EP. AND ADDRESS) Si ed on this date: tea` I 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 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 through Friday. Cremations done on Saturdays will be charged the additional $50.00. ' tt SINGlL1 N-EWALY FUNERAL HOME 407 Day Road Asbury,NY 128% (518)793-4459 � r i r "Customer's Designation of Intentions" Name of Deceased.: Cremation: (Sc6duled Date) (Location) Manner of Disposition of Cremated.Remains: ❑ Burial at ❑ Return to Family ❑ Entombment atOther (specify): I hereby designate the Disposition of Cremated.Remains and a8mowledge receipt of a Copy of this form. f �' gnature) (Printed Nam ) (Relationship to Deceased) (Address) J j i (Telephone Numh er) i "Cremated. Remains which shall not have been claimed. within 120 clays from the date of cremation may be disposed of by this firm by placement in a columbarium." Printed N�me of Funeral Director Si a of Funeral Director Date or Undertaker ""or Undertaker I TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF CREMATED REMAINS i Cremation: (Actual Date) (Location of Crematory) I Disposition of Cremated.Remains: (Manner of Disposition) (Location) (Date) Name of Person Making Disposition signature Date i #9 WHri'E:Funeral Home Copy YELLOW Family Copy PINK.Crematory Copy CUSTNTEN Rev.A/96 •I OSITI0�1 031 Rev.4/98 �P�vw AUTHORIZATION FOR CREMATION AND DISP CREMATION.NING NOTI CREMATION IS IRREVERSIBLE AND FINAL.READ THIS DOCU F:THIS IS A LEGAL DOCUMENT.IT CONTAINS IMPORTANT PROVISIONS CONGERMENT CAREFULLY BEFORE SIGNING. I/We,the undersigned,certifyfwarrant and represent that I/we have the full legal right and authority, d knowGf no 1��v�fng Pon who has a superior ii & aias priority right under state law,to authorize the cremation,processing and disposition of the remains of ame�t eceasea 45 (hereinafter referred to as the"Deceased"). ��} Time o Date of Death f Death - A M P.M. I/We hereby request and authorize (hereinafter referred to as the "Funeral Home")to take ame o unera nme possession of and make arrangements for the cremation of the remains of eceased at ame or ummatory (hereinafter referred to as the"Crematory"). sion and custody of the Funeral Home. to the posses I/We hereby authorize the Crematory to returnns of the C ema ory shall be fulfilled when the cremated remains of the deceased are returned to he I/We understand that the services and obligatfo authorize the Funeral Home to arrange for the disposition of the cremated remains o the possession and custody of the Funeral Home.I/We hereby Deceased as follows: Is special handling required? �yes , No Describe Suitable for shipping: Yes No Description of urn or container selected: Cemetery E` Deliver t0 ame an ress o eme ery Release to family ame o s�gnat amp y em r to ecerve remate emams Scattering at sea by Funeral Home or Funeral Home's agent Ship via U.S.Registered Mail* Address To:Name _- Other *Funeral Home and Crematory are not responsible for any loss or damage of cremated remains shipped via Registered Mail with the United fates Postal Service. ggains of the p The cremation,prothe rules n edulations and policies e(s of the Crematory and Funeral Home and the following terms and conditions: all governing laws, g in a 1. The remains of the cremation container.The Cretion unle matoy is authorfor ized d to remove and di ss received by se of handles,ornamentsland tany other resistant, noncombustible items attached to the cremation container prior to cremation.In the event the remains of the Deceased are received by ethe remains of the Deceased to be removed prior to cremation anstructed of nd placed in a combu in a casket or other container co tible other noncombustible materials, ontainer. I/we authorize I/We further authorize the Funeral Home or Crematory to make disposition of any such noncombustible casket in any lawful manner it deems appropriate. create a hazard 2. when placldOiradioactive he cremation ted The(n the remains of the Crematory will not ccremate any humsuch asan remains pacemakers, ch contain any type of when placed b implanted mechanical or r • agent device. employees,to remove an such mechanical devices from the remains of the Deceased authorize the Funeral Ho , TIFY THAT THE REMAINS OF THE prior to cremation, and s ose of s O items at its TAIN ANY TYPE t ion. I/WE HEREBY CER DECEASED DO D NOT OF IMPLANTED MECHANICAL OR RADIOA CT DEVICE. Please in *alone. devices which the Funeral Home is authorized to remove from the Listed below are all implanted mechanical and radioactive 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 containing the 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 persona articles accompanying the remains of the Deceased,the Deceased,are be recovered from the crem the cremationation on chamber,theyemaythorize that i- be separate( any items,other than the cremated remains of the , 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 pulverizef 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; container which is not designated for any type of shipment. 8. In the event the urn or container is insufficient to accommodate all of the cremated remains of the Deceased,any excess crematei .•o, n;nc will he niaced in a secondary container and returned to the Funeral Home,together with the primary urn or container.