Kendall, Lloyd OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
q \ Funeral Director 5)' (VCy1'fjbN -
Name ' 101 '��N�J �, �,`, Case#
Date Of Cremation
Time Cremation Started
Time Cremation Completed
Type of Container 0610Z-d Gaw'9.) eott-�
Remarks
I C.ks P- o V
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... PROS l�tv'����OiN C,E. 031 Rev.4/9&
AND FINAL.READ THIS DOCUMENT G' REFLLi 1 tsE! E TRENtATION,
represent that Uwe have the full legal right and authority,and know of no living r�N LVr
authorize the cremation,processing and disposition of the remains of g Pew who has a
o as the"Deceased"), superir,
w.
'� ame o e ase
Date of Death )/j!l� -
UWe hereby and authorize 3 Time of Dearn---�_�y - = 1ame, '
Possession of and make arrangements for the cremation of the remains of the Deceased at (hereinafter referred to as the "Funera M. t e
(hereinafter referred to as the"Crematory"). a")to take
ame o rematory
I We hereby authorize the Crematory to return the cremated remains of the deceased to the possession and custody of the F
I/We understand that the services and obligations of the Crematory shall be fulfilled when the cremated remaiMe
�-
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 are returnedmainsmaunerns
Deceased as follows: 07
Is special handling required? Y�No Describe of
k
Description of urn or container selected:
Deliver to Suitable for shipping: Yes No
Release to family ame an ress o eme ery Cemetery
ame o eslgna[ ecelve rema[ emams
Scattering at sea by Funeral Home or Funeral Home's agent aml yemr to
Ship via U.S.Registered Mail*
To:Name
u Other Address
*Funeral Home and Crematory are not responsible for any loss or damage of cremated
Postal Service. remains shipped via Registered Mail with the United States
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 t
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 ;7�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 containingg the remains of the Deceased will be placed in the cremation chamber and will be totally and
irreversibly destroyed by prolongedexposure 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.
I. 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.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.
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.
i. 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.
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.
I/We understand and acknowledge,that even with the exercise of reasonable care and the use of the Crematory's best efforts,it is
not possible to recover all particles of the cremated remains of the Deceased,and that some particles may inadvertently become
commmsled with Darticles of other cremated remains rPmainina in the rram.tic.n ni—h—..-,i/,....4u-- ____-
2� .
TOWN OF QUEENSBURY
PINE VIEW CEMETERY t
CREMATORIUM
� r
Quaker Road. Queensbury, New York 12804
Phone (518) Crematorium 745-4477 (if 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 rernains of:
(NAPAE) (SEX)
(STREET) (CITY) I (STATE) (ZIP CODE)
who died on l/ day of a„uQ„� 2003
at �dr }/1f Avg lU e-s:
(PLACE) (ADDRE )
Name and address of nearest living relative or name of person authorizing cremation:
)9M" L C o",„�
Relationship to deceased
Name of Funeral Home $':,,t �,�,� - 1,�<<1, 171.k�,J AJ.' �
IMPORTANT
I represent that to the best of my knowledge, the deceased has o as Zl 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 nnected with the cremation of said remains as directed, whether
such claims or demands-are e not wholly groundless, false or fraudulent.
VJ /,-) CJ
(WIT E ) (ADDRESS)
(SIGNATURE OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date: I