Lynch, Jeanne rrnW 1C OF QUEEVBU9 Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
runeral Director .!; 1*=44- /o�� �jt,Lc
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Date of Cremation " ,�� ` 01 a
Time Cremation Started "M
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SOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 (if no answer)
Cemetery 745-44.76
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)
(STREET) (CITY) (S E) (ZIP CODE)
who died on day of Y 1��� 20�L'
--60-A
(PLACE) (ADDRESS)
Name d address of ne rest living relative or name of person authorizing cremation:
Relationship to deceased
Name of Funeral Home 04
IMPORTANT
I represent that to the best of my knowledge, the deceased has has no cemaker 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
a ainst them b reason of or co ected with the cremation of said remains as directed, whether
u h claims o d ands are or re not holly groundless, faI �r fr ulent.
, k.
(WITNESS) (ADDR
c� &qp �����u�
(SIGNATURE OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date:
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.
SINGLMN-EWALY�YVNML HOW
Quembtiry,NY 13804
(518)793-"59
"Customer's Designation of Intentions"
Name of Deceased: JJ 155 , JA
Cremation: toL
(Scheduled Date) (Location)
Manner of Disp lion of Cremated Remains:
i
1 Burial at oL= c ro v X Return to Family
-�- - ec� �P
er � k
s -�——
I hereby designate the Disposition of Cremated Remains and acknowledge receipt of a copy of
this form.
(Sign e)
(Printed Name) rk (Rel do hip to Deceased)
Addr
D
(Telephone Number)
"Cremate Remains which shall not have bee Claimed. within 120 days from the date of
cremation may be disposed. of by t firm by acement 'ip a columbarium."
t
Printed Name of Funeral Director _ Signature of Funeral Director Date
or Undertaker or Undertaker
a
TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF CREMATED REMAINS
` Cremation: i At
(Actual Date) (Location of Crematory)
Disposition of Cremated Remains:
(Manner of Disposition)
(Location)
(Date)
Name of P6rsoiu Malting Disposition Signature Date
#9 WHrM-.Funeral Homo Copy Yellow F—Ay Copy PINK:Crematory Copy CTTSIlV'1'k'N Rev:4/96
r
AUTHORIZATION FOR CREMATION AND DISPOSITION 031 Rev.4198
NOTICE: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 I/we have the full legal right and authority,and Ic w of livingperson/who a a su for
priority right under state law,to authorize the cremation,processing and disposition of the remains of ! /�!)'J) CI
(hereinafter referred to as the"Deceased"). ameoe
ased
(e .\ Ch)`Date of eath Time of Death-Ilea , A.M. P.M.
J;
I/We hereby request and authorize N — � (hereinafter referred to as the "Funeral Home")to take
Name o anera Home n
possession of and make arrangements for the cremation of the remains oft Deceased at � e
(hereinafter referred to as the"Crematory"). Name 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 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 fellows:
Is special handling required? Yes J( No Describe
Description of urn or container selected: Suitable for shipping: k,' Yes No
❑ Deliver to Cemetery
ame and Address of cemetery
Release to family
Name o esignated Family Member to Receive Cremated Remains
Scattering at sea by Funerarflome or Funeral Home's agent
Ship via U.S.Registered Mail*
To:Name Address
E 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 CONTAIN ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE.
Please initihl 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
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 iewelrv,and other personal
articles accompanying the remains of the beceased,may be destroyed during the cremation process.II a further authorize that if
any items,other than the cremated remains of the Deceased, are recovered from the cremation chamber,they may be separated
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 pulverized
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 a
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 cremated
remains will be.placed in a secondary container and returned to the Funeral Home,together with the primary urn or container.
9. I/We understand and acknowledge,that even with the exercise of reasonable care and the use of the Crematory's best efforts,it is