Fowler, Helen . TOWN OF QUEEM
.s5BU9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director ,Ij�66 jVjZ_ V,�'/S(�l)/
Name &aLy Case #J
Date of Cremation '- o p7�ao2
Time Cremation Started /0?0/0/0/M r
Time Cremation Completed o2 �0!1 11-'111V7f
Type of Container -�{i9�C,��Tj� �/�✓/I ,�� o�/��Ji �19$',�
Remarks : 7�
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY&CREMATORIUM
Quaker Road, Queensbury, New York, 12804
Phone(518) Crematorium 745-4477 of no answer Cemetery 745-4476
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, in Accordance with and subject to its
Rules and Regulations to Cremate the remains of:
r )J.Y? f0 LA..f Fr-
(Name) ) (Sex)
(Street) (City) (State) (zip)
who died on C t4 day of 20 CZ
at
(Place) (Address)
Name and address of nearest relative or name of person Authorizing cremation:
-7 - GZr 61-1 Y-
(Nam (Address)
Relationp-Np.to the deceased
Name of Funeral Home V%
IMPORTANT:
I represent that to the best of my knowledge, the deceased has o has no acemaker in his or her body.
(Circle One)
certify that I have the full power and authorization to arrange For the cremation of the remains and to
direct the disposition of the cremated remains, that any personal possessions have either been removed
or may be destroyed, and agree to protect, defend and save harmless Pine View Crematorium from any
and all claims and demands for loss or damages which may be made against them by reason of or
connected with the cremation of said remains as directed, whether such claims or demands are or are not
wholly groundless, false or fraudu)lent.�
i ess) v� (Address)
(Signature of Relative or Legal Rep. and Address))
Signed on this date: F&8��
UGAN &VZMT,VtVQMAX,-U. 1fflCZ
Qmmsbwy.16w VA 12804
(118)7+2-1114
"Customer's Designation of Intentions"
Name of Deceased:
`r S � ?C�� OZ
„•, Cremation: ]]
c... �� � it C o-+-•w L:
( cheduled Date) (Location)
r Manner of Disposition of Cremated Remains:
❑ Burial at Return to Family
El Entombment at ❑ Otber (specify):_,
I hereby designate the Disposition of Cremated.Remains and acknowledge receipt of a copy of
s
,.. this form.
i$n e)
LA r, f t II ram.. ULl) rs'_t t.� b» J r7 /O ttiJ
(Printed Name) (Relationslup to Deceased).
(Address)
}" (Telephone Number)
4'
"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 i a columbarium."
Printed Name oflzuneraT Director igrnatur Funeral Director DX.
or Undertaker or Undertaker
r
TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF CREMATED REMAINS
t
Cremation:
(Actual Date) (Location of Crematory)
Disposition of Cremated Remains:
k (Manner of Disposition)
(Location)
(Date)
Name of Person Making Disposition Signature Date
#9 WHTTE_Funeral Home Copy YELLOW:Family Copy' PINK:Crematory Copy CUSINTEN Rev.9J96
i
031 Rev.4/98
�vw AUTHORIZATION FOR CREMATION AND DISPOSITIO
w4
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 know of no living person who has a superior
�Deceased priority right under state law,to authorize the cremation,processing and disposition of the remains of ame o s A.M. -. P.M.
(hereinafter referred to as the"Deceased"). Date of Death $ Z Time of Death -
(hereinafter referred to as the "Funeral Home")to take
VWe hereby request and authorize ame o o ra ome —
r�
possession of and make arrangements for the cremation of the remains of the Deceased at .��
rvame of l,remaiory
(hereinafter referred to as the"Crematory").
ion and custody of the Funeral Home.
I/We hereby authorize the Crematory to return f the C ema ory shall be fulfilledthe cremated remains of the ewhen the cremated r to the emains of the deceased are returned to he
I/We understand that the services and obligations o
possession and custody of the Funeral Home.VWe hereby authorize the Funeral Home to arrange for the disposition of the cremated remains o the
Deceased as follows:
Is special handling require? Yes<No Describe
Suitable for shipping: i=i Yes - No
Description of urn or container selected: Cemetery
Deliver to ame an ress o eme ery
Release to family ame o agnate amp y em r to ecetve remat emams
Scattering at sea by Funeral Home or Funeral Home's agent
Ship via U.S.Registered Mail*
Address
To:Name
Other
L*Funeral Home and Crematory are not responsible for any loss or dmageof cremated remains shipped via Registered Mited fates
stal 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,d b and the the Cre ao following
ng terms an combusti leak
ble,
1. The remains of the Deceased will not be accepted for cremation unless dispose ornaments and
resistant,rg` itemsiattachedcontainer.
to t e crema on containe is r priord to rem(to cremation.Inwe and �the event th r nonco of the Deceased are
noncombustible
received by the Crematory in a casket or other container constructed of metal,fiberglass,or other noncombustible materials,
Iece authorize the remains of the Deceased h 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.
ces implanted in the remains of the Deceased (such as pacemakers, etc.) may create a hazard
2. Mechanical or radioactive devi
when placed in the cremation,chamber. The Crematory will not cremate any human remains which contain any type of
active device. In the event the remains of the Deceased contain such a device I/we hereby
implanted mechanical or radio
mployees,to remove an such mechanical devices from the remains of the Deceased
authorize the Funeral Home,its agents and eretion. I/WE HEREBY CERTIFY
prior to cremation, and dispose of CONTAIN ANY ch items at its discTYP F IMPLANTED MECHANICAL OR RADIOA TIVE DEVICE.
DECEASED DO -. DO NOTi�
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 jewelry,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 herebl 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.