Merkle, Ardis LO Y V N OF QUEEN.,5BU.WY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, INEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name �q)rmi" , Case #
Date of Cremation �� 02 — v2coo2
Time Cremation Startedzj
Time Cremation Comoleted4 ��� / /M I
Type of Container--j&f=/ &6� 0
Remarks :
/ 1ArI �M
� t
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:
AahlS
(Name) (Sex)
BA6� Qb\ L)Lc-Ns,eL) t'1-4 1aIS-6 if
(Street) (City) (State) (zip)
who died on day of A LJC y sP 20 0,_
(Place) (Address)
Name and address of nearest relative or name of person Authorizing cremation:
(Li i Pet >zs'J.E VANAP,L I-Aril: LA1-sli LOIFLLA,I�' AI,y-
(Name) (Address)
Relation;,Np.to the deceased �AtJC. (� i 2 It4 LA kN/
Name of Funeral Home_ AnC +
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 Relative or Legal Rep. and Address))
Signed on this date: 1 ? 0 11
REGAN& DENNY FL'N L >� Wvl(- L:'
53 Quasar Road
Quembum Now York 12&9
(518)792-1114
"Customer's Designation of Intentions"
Name of Deceased.: AR;L i c.
Cremation: V i c, t N/ .' .C. r"1 /c L�/
(Scheduled Date) (Location)
Manner of Disposition of Cremated.Remains:
❑ Burial at A Return to Family
,a
❑ Entombment at ❑ Other (specify):
I hereby designate the Disposition of Cremated.Remains and acknowledge receipt of a copy of
this form.
' >: —
(Printed Name) (Relationship to Deceased)
(Address)
(Telephone Number)
"Cremated Remains which shall not have been claimed within 120 days from the Afait of
cremation may be disposed of by this firny by placement in,�.colu ii- M.
' Printed Name of Fune I r.4T,. Signature of Funer erector Date
a,
or Underta ' �.��µ�. �,"' or UnderrQer
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.4/96
ATTACH AUTHORIZATION FOR CREMATION AND DISPOSITION
3 BOOKLET
HERE TI :THIS IS A LEGAL DOCUMENT. IT CONTAINS IMPORTANT PROVISIONS CONCERNING CRLiNtATION�
CREMATION IS IRREVERSIBLE AND FINAL. READ THIS DOCUMENT CAREFULLY BEFORE SIGNING
e,the undersigned;"certify,warrant and represent that I/we have the full legal right and authority to authorize the cremation, processing and
ains o{{� a
disposition of the rem S , F1CL,� (hereinafter referred to as the"Deceased").
Name of Deceased �
r/ ,, ` Date
of Death i( �;j!',? Time of Death l IN A.M. ❑P.M.
I/We hereby request and authorize �/�l ' !V L� 11 - %` (hereinafter referred to as the"Funeral Home") to
Name of Funeral Home _
take possession of and make arrangements foe he cremation of he-remains of the Deceased at i�Til/
(hereinafter referred to as the"Crematory"). Name o4 Crematory
I/We authorize he Crematory to return the cremated remains of the Deceased to the possession and custody of the Funeral Home. I/we
understand l services obligations the Crematory shall he
s mt d are eto
thepossesssionand custodY of the Fn al Home. I/We hereby authorize the Fuea Home to arrange for the dispositionof the returned
cremated
remains of the Deceased as follows:
Is special handling required? ❑Yes �;e< Describe
i
Description of urn or container selected: &Q1V46 It ZLc suitable for shipping: �es ❑No
❑ Deliver to Cemetery
Name and Address of Cemetery n /
Release to family R z-.(_/;.._ /� 13 /-'7 e 1;7, ,tiC"/. e5 (�E x r C LP �c7 �' � � Gc1 1� �•�
Name of Designated Family 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, rocessing and disposition of the remains of the Deceased authorized herein shall be performed in accordance with all
governing laws,t e 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 cremationAn he event the remains of the Deceased are received by the Crematory in a casket
or other container constructed of metal, fiberglass, or other noncumbustible 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 ern lanted 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
lante
he
he
contain
a device, I/we ereby
athorizet he Fmeclanical or uneral Home radioactive is agents device.em 1 employees, loveremains
such mechanical
ecchan cal devices from the remains of the Deceased
g P Y Y
prior to cremation, and dispose of such items at its discretion. I/WE HEREBY CERTIFY THAT THE REMAINS OF THE DECEASED
DO 0 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 crerrTation chamber and will be totally and
irreversibly destroyed by prolonged exposure to intense heat and direct flame. 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 Deceased, 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 Deoeasec d di posed,of by the Crematory
5 n�yhmit bytouthorize the hinges,latches, nails,jewehy separate
and precious metals remove , and o dispose of sum the cremation hclmaterials.
er noncombustible materials, including, but
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 designed for any type of shipment. ,
t 7
Q T._ aL- -...-...t tL- ..e_ ..« «+ :« �..� ,e.+ + � .... ,l�+o .11 -f +l,o n.o. .4-A rama;nQ of A. T_) na Q A anv PvrPQQ vramafP.J
ATTACH BOOKLET AUTHORIZATION FOR CREMATION AND DISPOSITION
HERE NOTICE THIS IS A LEGAL DOCUMENT. IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION.
nCREMATION IS IRREVERSIBLE AND FINAL. READ THIS DOCUMENT CAREFULLY BEFORE SIGNING
e,the undersigned, cer*,warrant and represent that-4 e ve the full legal right and authority to authorize the cremation, processing and
disposition of the remains o (hereinafter referred to as the`Deceased").
Name of Deceased i 3
Date of Death "Z, Time of Death 4o ]AM. ❑P.M.
-VWe hereby request and authorizef(ir �y [dU (hereinafter referred to as the"Funeral Home")to
Name of Funeral Home
tape possession of and make arrangements for the cremation of the remains of the Deceased at
(hereinafter referred to as the "Crematory")• Name of Crematory
*We authorize the Crematory to return the cremated remains of the Deceased to the possession and custod of the Funeral Home.,'.1"/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.*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 XNo Describe
Description of urn or container selected: A.:ff6eimIZes - 'c� LAZ - Suitable for shipping-, Wes ` ❑No
❑ Deliver to Cemetery
Release to family L Name and Address of Cemetery
.f'1. �, ! �"
Name of Designated Family Member to Receive Cremated Remains
❑ Scattering at sea by Funeral Home or Funeral Home's agent
❑ Ship via U.S. Re istered 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.
he
goe cremation,overnin laws leo�e,re ula disposition
and policies the Cremat remains ofory and Funedral Home ea herein e ollo shall bete performeds d conditions:
ance with all
governing g P 13' g "
I. The remaips 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 noncumbustible materials,t1we authorize the remains of the Deceased to be
removed prior to cremation and placed in a combustible cremation container 4/We further authorize the Funeral.Home or Crematory to
make disposition of any such noncombustpible casket in any lawful manner it deems appropriate.
2 whenha laud in the or active cremadti nces chamblerted Then the Crrematory s of will noht cremated y humauch as naremainsswhich ontainaan a hyazaof _____v..
implanted mechanical or radioactive device. In the event the remains of the Deceased contain such a device, $/e 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 dispoa of such items at its discretion*[WE HEREBY CERTIFY THAT THE REMAINS OF THE DECEASED
DO = 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 he 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�l'/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 Deceased, may be destroyed during the cremation process. /We further
authorize that if any items, other than the cremated remains of the Deceased, are recovered from the cremation chamber, they
may he separated from the cremated remains of the Deceased and disposed of by the Crematory.
5. /W(enot lu et bd touhmges,latches, nailsthorize the ,Crematory
and preC to separate aous meta remove ls, and to dispose®f em the cremation �c a�tember llaIs.noncombustible materials, including, but
6. Following cremation, the cremated remains of the Deceased, consisting primarily of hone 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 designed for any type of shipment.