Stiles, Mayhew L O W OF QUEEN,5BUJ�Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD. QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name A w � � ji �� Case # L�
Date of Cremation 1 b — 2 `l -2
Time Cremation Started
Time Cremation Completed 11 . 3 JA
Type of Container
Remarks :
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in 35 Wes,
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TOWN•OF QUEENSSURY •
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:
AuhZ S-f- 1 rS A
(Nam (Sex)
jy )/1 /\J
(Street) (City) (S te) (zip)
who died on �7 f� day of 20 0
at /9 - b U.�
(Place) (Address)
Name and address of nearest relative or name of person Authorizing cremation:
(Name) (Address)
RelationpNp.to,the deceased 1�;
Name of Funeral Home - l
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or as no pacemake 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 tive or Legal Rep. and Address))
Signed on this date: 6
53 Mw Y it 12804
(518)792-1114
e
"Customer's Designation of Intentions"
Name of Deceased.: h) cx U 6 r w .5 L f
Cremation: 1 €:) ,5 ,0 z
Scheduled Date) (Location)
Manner of Disposition of Cremated Remains:
❑ Burial at X Return to Family t"41 rw `
❑ Entombment at ❑ Other (specify):
I hereby designate the Disposition of Cremated.Remains and acknowledge receipt of a copy of
this form.
� k
( ignature)
(Printed Name) (Relationship to Deceased),
(Address)
�a �rr . i4bu,-4
c'
,S!IS'- 17 Y 3- 72 2 R
(Telephone Number)
"Cremated. Remains which shall not have been Claimed within 120 days from the date of
. Cremation may be disposed of by this firm by placement in a columbarium."
� ' A
J .
Printed Name of Funeral Director Signatur#4 Funeral Director Daee
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)
is
Name of Person Making Disposition Signature Date
#9, WHITE;Funeral Home Copy YELLOW.Family Copy: PINK:Crematory Copy CUSINTEN Rev.Q96
I HEREBY EXPRESS TO MY SURVIVORS MY EARNEST DESIRE AND REQUEST THAT ON MY DECEASE MY BODY SHALL
j9E CREMATED AT PINE VIEW CREMATORIUM, ON QUAKER ROAD, TOWN OF QUEENSBURY, NEW YORK AND FURTHER DO HEREBY
ORDER, DIRECT AND AUTHORIZE SUCH CREMATION.
K(Signed)
(Address) 823 County .Tt. 61
Shushan, NY 12873
r
Witness /
Address 80 Main St. , Greenwich, NY 12834
Dated January 27, 1996
TO BE ENTRUSTED TO THE SIGNER'S EXECUTOR OR NEXT OF KIN
(Return copy to PINE VIEW CREMATORIUM, Quaker Road, Queensbury, N.Y. 12801)
ATION AND DISPOSITION 031 Rev.4/98
AU
v THORIZATION FOR CREM �1
�w4w
� NO"fICE:THIS IS A LEGAL DOCUMENT.IT CONTAINS IMYORI'ANT PROVISIONS CONCERNING CREMATION. .
CREMATION IS IRKEVERSIBLE AND FINAL.READ THIS DOCUMENT CAREFULLY BEFORE SIGNING.
=.
right and authority,
I/We,the undersigned,certify,warrant and represent that I/we have the full legal y,and know of no living per who has asuperior
t
priority right under state law,to authorize the cremation,processing and disposition of the remains of Name of uec7—
(hereinafter referred to as the"Deceased"). Date of Death U Z
Time of Death _ A.M. ' P.M.
I/We hereby request and authorize .S
(hereinafter referred to as the "Funeral Home")to take
ame o unera me _
/G
possession of and make arrangements for the cre tion of the remains of the Deceased at
ame o rematory
(hereinafter referred to as the"Crematory").
ceased to the possession and custody of the Funeral Home.
I/We hereby authorize the Crematory to return t the C ema ory hall be fulfilledremated remains of the ewhen the cremated remains of the deceased are returned to he
I/We understand that the services and obligations of
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 follows: »a n
Is special handling required? � ,Yes X No Describe
Suitable for shipping: f-� Yes No
Description of urn or container selected: Cemetery
-I Deliver to ame an ress o eme ery
Release to family ecerve remat emams
-- Scattering at sea by Funeral Home or Funeral Home's agent
Ship via U.S.Registered Mail*
Address
To:Name
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:
the
1. bustible, leak
resistant,
e istantremains
i of the d cremation container.The Cremeceased will not be atory is authorized to remove and difor cremation unless received spose of handles,ornament in a s�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 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: /
Disposition
Description of Implanted Device _ r _
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 ewelry,and other personal
articles accompanying the remains of the Deceased,may be destroyed during the cremation process.I/i 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
romainc will be Dlaced in a secondary container and returned to the Funeral Home,together with the primary urn or container.