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Waentig, Albina OF QUEEN,5BU- PINEy VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director�/V0(,r�,�"�1/�(y Name /�.L�l�V,� A, , T;'� Case # 3 Date of Cremation " Time Cremation Started-6 Time Cremation Completed Type of Container ��� � 0/1�/ Remarks : , / CA Aq < TOWN OF QUEENSBURY PINE VIEW CEMETERY&CREMATORIUM Quaker Road, Queensbury, New York, 12804 f J Phone(518) Crematorium 745-4477 of no answer Cemetery 7454476 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) •-a i 1�� I�jY (Street) (City) (State) (ZIP) who died on dayof U� 2O0 Z at Lc_N!S (EA LL,S Ro S iot ( el (Place) (Address) NaMp and address�Qf nearest relative or name of person Authorizing cremation: 0 A/o 2A /`►. _ �o!'L r3a�� ���O 1r -c:/�5 i ���� ,�►�c�-�C�� /��/�CJG/(Name) (Address) /(Y' Relation;hjp.to,the deceased Name of Funeral Home -e 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 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. (Witness) (Address) (Signature of Rela ve or Legal Rep. and Address)) Signed on this date: i Qursewbury,New York 12 (519)792r 1114 'd C, "Customer's Designation of Intentions" Name of Deceased.: /Q-L LA 1 t�!A 1t11fi L/V 11(:, Cremation:_ '3�1��, 101,l6 Vt 5-W CIZ PJJrg (Scheduled Date) (Location) Manner of Disposition of Cremated.Remains: ❑ Burial at , Return to Family ❑ Entombment at.. © Other(specify): I hereby designate the Disposition of Cremated. Remains and acknowledge receipt of a copy of this form. (Signature) OpfQ �I+.MIV (Printed Name) (Relationship to Deceased) 11 b,AS (36} I SA Dom. (Address) s - ��r� (Telephone Number) "Cremated. Remains which shall not have been claimed. within 120 clays from the date of cremation may he disposed of by this firm by placement in a columbarium." Printed Name of Funeral Director ,Signature of Funeral � ctor Mte or Undertaker or Undertaker TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF CREMATED REMAINS Cremation: (Actual Date) (Location of Crematory) Disposition of Cremated. Remains: (Manner of Disposition) (Location) (Date) Name of Person Malting Disposition signature Date #9 WHITE:Funeral Home Copy YELLOW Family Copy PINK:Crematory Copy CUSINTEN Rev.Q96 111 AUTHORIZATION FOR CREMATION AND DISPOSITION NOTICE:THIS IS A LEGAL DOCUMENT.IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATIO V. �31Rev.a/9s 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 living person who has a superior priority right under state law,to authorize the cremation,processing and disposition of the remains of (hereinafter referred to as the"Deceased"). �+ t ame o ece Date of Death Q-1 C Time of Death — I/We hereby request and authorize 12 o A.M. amenFume o e (hereinafter referred to as the "Funeral Home")to take possession of and make arrangements for the cremation of the remains of the Deceased at (hereinafter referred to as the"Crematory"). /NCi Vic Itil name of Cremator-y 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' 2 Yes �1Vo Describe Description of urn or container selected: Deliver to Suitable for shipping: ❑ Yes D No f� Release to family �0��F�p,/��/ame an ress o 'eme ry Cemetery ame J Scattering at sea by Funeral Home or Funeral Home's agent o Igoe[ am.y em r to ecewe remate emams Ship via U.S.Registered Mail* To:Name Address Otho! *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 teams 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 o the Crematory I/we authorize i"cask"4w-other C9BtaiDer constructed ofMetat,fiberglass,or othernoncombustib a-m�Ue ihfi�,' rize 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 t 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 otrthe Deceased prior to cremation, and dispose of such items at its discretion. I/WE HEREBY CERTIFY THAT THE REMAINS OF THE DECEASED DO I I DO NOT !CONTAIN 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 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 '-welry,and other personal articles accompanying the remains of the beceased,may be destroyed during the cremation process.I/We 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.