Hayes, Samuel . rf-oWN OF QUEEMs5BUir�Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD. QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name 5A-)�x V c: H v iEc Case #
Date of Cremation LO
Time Cremation Started Q _ A
Time Cremation Comoleted �-
Type of Container CA o-J l3 v v�,\?Q co '— I C, sly
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L^ i AUTHORIZATION FOR CREMATION AND DISPOSITION a.s wr
hOrJC :THIS ISA LFX;AL DOCUMENT:iTCUNTAINB LMPORI'ANI'PROYIs1ONs CO!VCBRNING CREMATION.
CREMATION IN IRREVERSIBLE AND FINAL.READ THIS DOCUMENT CAREFULLY BElrt'RE ALGNING•
Me,;be rnodersigned.cisMI,wormnt and•represeot that Vwe ben the mall Imo right and aut►ashy,mad keow to mvbg past"Title vas vessel"
pr6dir,tape mador stale law,to ewarrio the me adoa,prortaW,g sad dhis.01tar of this nmalnsaf�� Q ril ueJ
(haronatbr reterree b a toe"Doceaad').
n Date of Drth 'Z Tlaa trDeaN ❑ A.7 :]T.M.
ItWe hereby regUM and ertbortor Ir. J One"IaR"rage'"'tar he "it" "iih""ry is is"
pomossian brand.make orrangraedoirar t�,mmKhm OfthenaWrof;e Deceem st_���sm Ila 'fawn-"I r^J
{twlgmfat rOArf+ed b me she'Y'lemataryr,l /
1:We hereby autheri"the Crematory is return this crenated mrsratne of the deamsed to the possession and eosiody of the Isowet Home.
V44e modenb,nd that the services shut oWigatbns of the Crematory shall be hllkkd when etas rremeeer,e,a.lna or Iha deaaeM m reWrned b the
pcaaaiaa mad custody of the Funerai Home.Vwv kwmby nuthorlm the Funeral Room to arrange err the dimpwhiu m o of the"crowd rvalas et the
I)"aseW q sslb o ��`
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Description of ore be esvlsiaa sdvdtdi, AWa►ls gr tldspiag: O Ym ON*
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7b:Name Aelsrest
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,ere ea m rer moory ore no responsibleany oa or mega eremaW estimates oh pad vie Registeredo rates
FaoW 9v"itt.
The cremation,proeesain and disposition of the remains of the Deceased authorised herein shall be performed in accordance with
all g,evermimgtons,the rues,regulations and policies of the Crematory and Fuaer@I Hoaa,and the followinl terms andconditlons:
1. The remains of the Deceased will not be accepted for cremmiiult unless received by the Crematory In a cortbttlt161e,leak
resistant,ri■■id cremation container.The Crematory Is authorised to remov had cilTge of handles,ornaments and any other
nomeombrlotibit items attached to the cremation comtahmer prior to cremmt�U.Ion bite event the remains of the Deceased are
rectived by the Crematory in a casket or other container constricted of metal,fiberg¢l1ass,or other noncombustible materials,
brae authorise the remains of the Deceased to De removed prior to tretnatlon and placed In m combustible cremation container.
VWe further authorise the Funeral Horne or Creaselory to make disposition of any suck noncombustible casket in may lawful
monner it deatmb appropriate.
2. Mechanical or radioactive devices implanted in the remains of the Deceased(each as pacemakers,arc.)may create a hazard
when placed In the cremation clamber.The Cremvlw;v will not cremate anv human ains which contain ally t pe of
pWl
Imikst m rem
echanical or ro lioaclive device.In the event the remains of the'Dec000ed contain such a device.Uwe Hereby
srthorlse The Funeral Home,its agmb and eraployll",to remove anYY oucb tuechattica3 devices from the remains of the Deceased
prior to cremation,and dispose M such Uonto at la discretion.IIVFE HEREBY CERTIFY THAT THE REMAINS OF THE
DECEASED DO L' DO NOT L7 CONTAIN ANYTYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE.
Pkaw initial ass.
Listed below are all implanted meckrtical and radioactive dcricee which the Funeral Hoerr is authorized to remove from the
remains of lice Deceased prior to cremation,mad dispose of so indicated:
If no brstrattlon Ra•disposition N given,such Itches rye be disposed brat the discretion orthe Funeral Home.
3. Tate crenmakni container coaisininB6 the rcwuie s of the Deireitd will be placed in the cremation chamber and will be toiuliy and
irrrvt rsiblyy destroyed by prolonBrd axposure to intense heal and direct flame.IMr authorize the CrNnator'y to open the cremation
chamber'luring toe ensn illoo process and reposition the+vivalus or the Deceased in order to Nativist a complete and thorough
cremmllon.
n. Certain rietm,inciala bat not limited body prostheses,eleatores,dents)bridgework,dental fRRuas.fe rel%andetkerpenonal
anitlss atoorapwtying to or,
orlhe�eoeased,may be destroyed dnrtna Ike cremation pvrocom,''4t''WWe farffkkor hathorlie that if
any stems,other than the cremated remains of the Deceased,are recmeirt>tl-horn like cremation chamber,they may be separated
from the cremated retmint,of the Deceased and disposed of by the Crematory.
S. 1,WeherebyauthorizetheCrematorybseparalaandremovefr•:+othecremmthntchamberamnonmtnbwdbleIatteWs uciuding,
bit not handed to,hinycs,latches,ails,1tweiry and predotu metals,mad to dispose of such materials.
6. Fenlowi. the cremated remains offfit Deceased,codsWol primarily of bone fragments,will bearechmalrally polveristed
to an unidentifiable consistency prior to placement to an urn or otter mom taliffat
7. Unites on urn or container suitable for shipment is purchased,the Crematory will place the cremated remains of the Deceased It,a
container which to not designated for say type o►shiprnent.
S. In the evgtt Use urn ur coitainer to tatufllelrnl to mccanntodote all of the cremated remoias of the Deceased,anv excess cremated
,*anal s will be placed to a secondary container sad returned to the Funeral Mwae,together with the primary urn or comiainsr.
9. 1,44'e widerimad and acknowledge,that even with the exercise of raaeonatlk care and the use artist Crrtnalnry's blot efforts,it in
nut possible to recover all particles or the crenated rornews or the Deceased,amid that some per thetas may iasdwrtendy become
commingled with porticles of other cremated temahms remaining In the cremation chamber god+or other devices utiilitd 10 process
the cremated remains.I(N'e hereby authorise the Crematory ro dispose of any much residual partlelet in any lawful rosnnar it
deems appropriate.
lh. Unlegs Uses kve spedfic written ioatrucUoae in this AUtborisation.the cremation,processing and dispasitlob of At remakes of the
Neceaaed will not be performal in accordance with any particular religious or ethnic customs.
Me event the cremated remains of the Deceased reml9in unclaimed for a period of 30 days,the Fbntral Hope sbm0 give wriilem
notice to mains by certified moil st the teddresn(es)indicated bellow. 1•We agree that In the event the cremated remains of the
Uereasdremalautrclaiaxd for a period ofiA do"aft"the dote such written nbufleseisnisrailed,tht,Feaerat Home isathortzed
aad dircefed to disperse of wile unclaimed cremated retaaiae of the Docreced in any iawfal Othnner if may deem appropriate.
12. Uwe agree to Indemnity,release aad 1e;d the Crematory,Funeral Florae,their offil.latea agents,eon pI1 naSves and asotgas,harmless
"in any and all loss,domages.lisbiNty or causes of action(iacludin attorneys'lees srrt�expenses CJ iltlaaaattlon))in connection with
the cremation and disposition of the cremated remains of the Decease,msoutrwixedbereiii,ormytourfrk;revLorrectly identify
the remake of the Deceased,disclose Ike presence of onq Implanted mechanical or radioactive devices.a),lake posisewina of,or
makt permanent arrangements for,the disposition broads remains.
13, Except as set forth fit this Authorization,no warranties,espreseed or implied,are made by the Funeral Hone,Crematory,o+any of
their respective affiliates,ageats.or employees.
14. L We understand that this document does"contain a complete and detailed descrljl tlon of every aspect of the cremation process.
,fttie acknowledge reeetvitsit,from the Funeral Home,a copy of the booklet entioed"Cremation Facts"containing addldoeal
explanatory information about the cremation process,
SIGNATURE OF PERSON(S)AUTHORIZING CREMATION AND DISPOSITION
VINt warrant that WI representations and statermento made herein are true and correct,and brat Uwe hsr,e read and dadeestmad the
lu•ovlehoms contained in this document,and that Itte have received the booklet entitled"Cremrehme Facts".
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WITNESS Dow:
/
10116/2002 11:04 S10-792-128 REGoW1&DEW-1Y PAGE 01
TOWN OF QUEENSBURY
PINE VIEW CEMETERY&CREMATORIUM
Quakaar Raad, QV6*nSbWy, New York. 12804
Phone(518) Crematorium 746-4477 of no answer Cemetery 745-4476
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Ping View Qmrnatoriurn, In Ac rdance with and subject to Its
RU In and ROVuletions to Cremate the rernalns of,
t'
(Name) 61 (Sex)
(Strael) (City) (State) (zip)
wh died onday of
t ace; (Address) --
Na m and address of neamst relmove or name of person Authorizing crematiion-
(N1 (Addrases)
R tionahjp.tc the dsaeaaed _ r r
Na:re of Funeral Hom"e
IMPORTANT
I r present that to the best of my knowledge, the deceased has or has no pacma ker in his or her body,
{I (Circle One)
1 oMnNy that f have the full power and suthor!zetion t4 arrange For the oremation of the remains and to
di ct the disposition of the cremated remains, that any personal posseeslons have elther b"n removed
or ay be destroyed, and agree to proteet, defend and save her, Pine View Crematorium from any
an aN QWMS and demands for lobs or damages which may be made against them by reason of or
Co acted wtth the vornaation of said remains as direeted,whether such claims or demands are or are not
Wh ly undiess,false or fraudulent.
Air
(Witness) (gtltlreS3) /
v
(Slgnaiure of Relative or legal Rep. and Address))
Signed on this date:_. .
10/16/2002 11:04 518-792-1287 RE.AN&AENNY 01346 PAGE 01
• -W G
TOWN OF QUEENSBURY
PINE VIEW CEMETERY 8 CREMATORIUM
Quaker Road,(Queens", New York, 12804
Phone(618) Crematorium 746.4477 of no answer Cemetery 745-4478
AUTHORIZATION TO CREMATE
Th 0 undersigned requests and authorizes Pine View Crematorium, In Acoordence with and subject to its
Ru lee and Reouistiont to Cremate the remains of:
( ame) (Sex)
(street) - � Du
(City) ( tste) (zip)
died on
day of
at
(Place) (6ldoreee)
1
Ntri M and address of nearest relative or name Of person Aulhorizirp cremation:
{Name) (Address) o�D
Rs�apon"'p.to the OKSOMed / fro IQ
Naf ne of Funeral Home
IMPORTANT:
i
I r"nt that to the best of my knowledge,the deceased has or has no pacemaker in his or her body.
f (Circle One)
I that I have the full power and wt1`100 tlan to orrangs For the cremation of the remains and to
d' the dhipusltlon of the cremated remains, that any personal po"Nalons have stther been removed
or sy be destroyer, and Spree to protect, defend and save harmieea Pine view Crematorium from any
an an claims and demands for lost or darnages which may be made against them by reason of or
Coed with the cremation of said remains as directed,whoftr such Claims or demands are or are not
wh ly oroandless,false or fraudulent
(Witness) (Address)
(sips of five s al Rep.and Address))
Signed on this date__ l�