Hahn, Mary Jane TO(wN OF QUEEVBU Ky
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD. QUEENSBURY, :NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name /y?Al-,z�j SAg Tlf i b wl Case # 'qY
Date of Cremation
Time Cremation Started 10
Time Cremation Completed
Type of Container
Remarks :
~
4w AUTHORIZATION FOR CREMATION AND
DISPOSITION �� �
N TI E:THIS IS A LEGAL DOCUMENT.IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION. 03litev.4/98
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 h
priority right under state law,to authorize the cremation,processing and disposition of the remains of
(hereinafter referred to as the"Deceased"), as a superior
rvame o ec
UWe hereby,request and authorize Date of Death /O1z L/�Z Time of Death /,t 30
�c��ri y/4�J �-62 v l*hAA! u- Pd trEtt? XG A.M. r! P.M.
Deceased at F (hereinafter referred to as the "Funeral Home")to take
Possession of and make arrangements for the cremation of the remains of the De
(hereinafter referred to as the"Crematory"). - � 020 t4l � ipii t47.---de r l m
[Name or C I We hereby authorize the Crematory to return the cremated remains of the dece rematory
ased to the possession and custody of the Funeral Ho
UWe understand that the services and obligations of the Crematory shall be fulfilled when the cremated remains of the deceased are returned t
Possession and custody of the Funeral Home.UWe hereby authorize the Funeral Home to arrange for the disposition of the cremated remains of he
Deceased as follows: o the
Is special handling required? I Yes X No Describe
Description of urn or container selected:
C] Deliver to Suitable for shipping: =-i Yes No
`i Release to family ame an ress to eme ery Cemetery
Scattering at sea by Funeral Home or Funeral Home's a en s-gnat amH y Member to ecelve remat emmns
gent
Ship via U.S.Registered Mail*
To:Name
Other Address
*Funeral Home and Crematory are not responsible
Postal Service. for any loss or damage of cremated remains shipped via Registered Ma777!n
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:
I. 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 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 oithe 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 VCONTAIN 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.
1. Certain items,including,but not limited to body prostheses,dentures,dental bridgework,dental fillings 'ewelry,and other personal
articles accompanying the remains of the beceased,may be destroyed during the cremation process.Me 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.
i. 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.
1. 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.
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.
I. 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.tnpethPr with the nrirA%ry rrrn nr..,.t.:.,or
SULLI'YAN•MINA RAN &POT=FUNKR+1L BOM'!6
407 Day Read
Qum,NY 12604
(518)792-2067
3
"Customer's Designation of Intentions"
Name of Deceased.:� z r}k' J,� /= �� r
1
Cremation:
(Scheduled.Date) (Location)
Manner of Disposition of Cremated.Remains:
Burial at l 1' a �/". ❑ 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)
(Printed Name) y f (Relationship to Deceased)
t
1,7 r Y � K,rT�sR rG+/ £lrlr G
(Address)
(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 placenipnt-il a columbarium."
Printed Name of Funeral Director ?r Sigma a of Funeral Director Date
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 Making Disposition Signature Date
*9 WHITE:Funeral Home Copy YELLOW:Family Copy PINK:Crematory Copy CUSIlVTEN Rev.4/96
Y
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to-dispose of the cremated remains as follows:
Mail to
Other arrangements-please specify:
If pulverization of cremated remains is requested, check here
POLICIES, RULES AND REGULATIONS
1. The crematorium will be open for cremations 5 days a week 7:00 A.M. - 3:30 P.M. Monday-
Friday. No Holidays or Sundays, arrangements can be made for Saturday. Pre-arrangements
by telephone for acceptance of remains is necessary.'
2. Pine View Crematorium is located on the grounds of the Pine View Cemetery, Quaker Road,
Town of Queensbury.
3. An authorization for cremation properly signed by the nearest next of kin or other authorized
person stating that they do have the power and authority 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 and/or disposition of said remains as directed, whether such claims or demands are,
or are not wholly groundless, false or fraudulent. This authorization in addition to a regular
burial permit must accompany the remains.
4. All remains must be encased in a casket or suitable alternate container. Caskets and
containers must be of combustible material. No Styrofoam or plastic containers will be
accepted.
5. The question relative to cardiac pacemakers must be answered on the authorization to
cremate form before the remains will be accepted.
6. Unless other arrangements are made the cremated remains will be mailed via Registered
U.S. Mail within three days of cremation to the funeral home handling the service. There will
be a$25.00 charge for this service.
Cremation, Administration Costs and Recording Fee: Adult$300.00 Children (age 13 months to
12 years) $150.00 Infants (stillborn to 12 months) $100.00
Additional $50.00 charge for cremations done after 3:00 P.M. Monday through Friday.
Cremations done on Saturdays will be charged the additional $50.00.
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road. Queensbury, New York 12804
Phone (518) Crematorium 745-4477 (if no answer)
Cemetery 745-44.76
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:
1111 A-,2%l ���� �A•tir� FEmg lF .
(NAME) `` (SEX)
9 StE✓Er✓ St /'Er''S X4 STATE V (ZIP CODE)
(STREET) (CITY)
who died on , day of 20 0,?,-
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Relationship to deceased SD!✓
Name of Funeral Home.Su//ivr�►� I19�rah /�ff�2
IMPORTANT
I represent that to the best of my knowledge, the deceased has or as n 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 deman are or are not wholly groundless, false or fraudulent.
(X '�_
WIT SS (A DRES
(SIGNATURE OF ELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date: