Dane, Dorothy 70WN OF QUEEVBU9�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name ' 12 Pfl� E Case#
Date Of Cremation — Le 0
Time Cremation Started
Time Cremation Completed ` l 1 �
Type of Container C,�4 � 3lp A )-U
Remarks
T duo tz d S SS
4 5r "'l
f�l/IV20a3 1.2,02 519-792-1237 PEW&j)Ei•8Tt" tt1.a4b
TOWN OF QUEI=i`I58URy ' �-
PINE VIEW CEMETERY&CREMATORIUM
quaker Road,Queensbury,New York,12604
Phone(5.48)Crematorium 745-4477 of no answer Cernetery 745 4476
AUTHORIZATION TO CREMATE
in Accordance with and subject to its
The ndemlgned requests anmt ins or res Pine View
Crematorium,
Ruie�and Regulations to ure
a e- �--- of i
(Sex)
(Norm)t�
(Street) (City)
..�.
20-�—
day of
v,h died on'
at (Address) .
(Place)
lngNa a and address of nearest relative car nam®of person Authnrizt-y cremation_
`(Name) (Address)
Raj tionShtP• •
to the deceased ' c
Na Tie of Funeral Home
IMPORTANT:
present that to the best of my knowledge,the deceesed has yr �scernaker in his or her body.
I P (Circle One)
llon of the
s and to
( rtify
that l have the toll Folder and autharizetion to a eno�rt®1posses�on or the nhave either been nrernoved
dlr ct the disposition of the crernated reed, e, that any p reason of or
or rr,a ;�e destroyed, and aytee to drotect, defend and save harrnlesa Pine View Crematorium from a,�y
y es which may be rdtadt against them by
an all cialms and dernandg for toss of damag
co Heated with the cremation of Said remains as drrected,whether such claims or demands are yr are no
Wt ally groundless,false or it Went.
(Witness) (Address)
(Signature of RGhWvre or Loge RQP and Ad ress)) 4;3 a10-�
Signed on this date: i
01 13r'2,C C 3 12": 19 6082504370 HOMESTEAD HERRIC K' PAGE Oi-
23
01/13/2003 13: 32 518-792-1287 REGANSDEI.11V 01346 rr-tur e'"
itdww vxsrAp c;Apmri tNr— c7W 461•4575
XN
AUTHORIZATION FOR CREMATION AND DISPOSITION12 � rotR� srye
' :7'FlE.5I5A Li✓C>,1L nt>'�±_!�'tl':N'I:I'f i:0)\'"fAlNS I1t1't:►RTAt�T 1'.tpYlltiiO:�S Ct7tiCf:RVINC CRE'btATION,
CTt MATIONISFR1?lWFRSl0Lt;ANDFtNAL.REAI,)'THISI►OCUK1 Nf'CARi �VJXYBEFORESICMNC.
b'Wa,tits under$$red,certify,warrant and rapremot that Vwr have the NK inal right and auchortty,and know of no living person Rho,1!a5 a 84eri9r
priority rgjit ua Itr suit ld%r,to authorize the creinaticm.prones,,hig and disposition of tfis remains of m)-„c ! ..
(hereinafter refs red to as the"Deceased").
Date of Peoth a 113 zl a 3 Time or Death CI A.M.! �j KNL
t/Vve bereby reqi est and authorize f;r a,•r., Ibercinaf'ter colt rued to as Rite "Funeral Ho e•'►to take
possession of aim walct arrangem eat ents for the crematlon or the rains of the Deceased at^ Qirt c Vie C J�
((hereinafter rek red to as the"Crematorpr7• w
t,',Wv hereby at thorize the Crematory to return the crevinted romellos of the deceased to the poRse56iao and custody of 01 Funeral Rome.
liWe under$tan that the srrvices and obtlgatiotis of,the Crematory shall be rultitltel when the cremated remain$of the decaased are U�tutined to the
possession and tally of the 1`uneral Home.I'We hereby suthoriata the Funeral Home to arrimse for the disposition of the cminsted molIsW of the
Deceased as roll as:
]especial lutdlhtg required? C:X� ?din 13raci'ihe_ r3sr rx �o �r1m.rl Nn>r.s.
uem"t in of urn or container$elected: __ Suitable for shipping: I J Yas C.No
Dolivi r to
Aelea e M fttnoliy — -
,ae 7 v ao.e rem' emun
�J Scattg ' g at sea by Funeral dome or Funeral Hams'-agent
i-i ship U.5,Registered Mail*
'[oi N1 me Address -- ---}------.-
other _ ---r ---
Mineral and rematorr are nOt raapcKls eJor any joas or damMe orcrernated remA nsshipped%in R4flatered 1►�1+1 wit t e :nit States -
�Pn�ataJ service I
The cremation y►rocessingg and disposition of the rerr,aitas of the Deceased alltborized herein shall be performed in accprd rise with
ail gj)verning l ma,the rubs,regulations acid policies of the Crematory slid Funeral Horne,and the following terms and cobdltions:
1. The rem$ as of the Deceased will not be accepted for cremation unless received by the Crematory In a co,mbuildble, teak
resistant, ipid cremation container.The Crematory is authorized to remove and dispose of handles,ornaments and only other
noncomb sable Items attached to the cremation container prior to cremation.In the event the remains of the Deceased are
received bW the Crematory its a casket or other container constructed of metal,fiberglass,or other ttolacombustibie niaterials,
I/we authorize the remalnx of the Deceased to be removed prior to cremation pptd placed in a combustible cremation c atainer,
Me fart er anthorize the Funeral Home or Crematory to mlakc disposition of amy such noncombustible casket in al y lawful
manner it deer s appropriate.
2. Mecbaanir.it or radioactive devices implanted in the remains of the Deceased(such as pacemakers,etc.)may create a hazard
wheft pla4 ed in the cremation chamber. The Crematory will nut cremate an hu.nailn remains whi6 cotntairt anv type of
impphate utechanlcall or radioactive device. In the event the remains of the yDeceased contain such a device Iltrt herebyy
Rufborize he Funeral Home,its agents and employees,to remove anv such mechanical devices from the remafna of+the peteased
prior to c ernatioo,a such ►terns at its discretion. I/WE HEREBY CERTIFY THAT TIfE REMAINS pF THE
TIECIEA$ D DU ('i DO NOT CONTAIN ANl'TYPE OFIMPLA;rTEDMBCHANIC4kLOR RADIOACTIVE I)EVICE.
Flesase one. +
Listed btl w arx all imppl.altted mechanical and radioactive devices which the Funeral Motile is aulhorlmd to remove�Otv the
rtmains o the Ileceasad prior to cremation,and dispose of as indicatmd:
ontfokw,1 wgkwlee Dr xi
p„erlprNa A npt�md oniee sae•
If no instlr ctiori for disposition is Riven,such items may be disposed of at the discretion of the Funeral Home.
3. The cremation container containkogg the rrmains of the Deceased will be placed its the cremiLdowL chamber and will be to�tally and
irheversibl destroy ed by prolorngedexpraSure to intense heRt and direct flame.l/We authorize t11e Crematory to oppen the=11 atiolt
chamber uritag the ere 'lij�on process and reposition tthe rentalns of the Deceased 1n order to fasllifat.e a eomple3c and !borough
cremation
4. cre Certain It zrxs,itrcluolin .but not limited to body prostheses,dentures,dental bridgework dental fllUugsllewelry,and ether!personaIf
l
articles otthpart 'tng�he reimains of the t4ceaoed,stay tie destroyed during the cremation pfoce h a further authorize that d
any Items other than the cremated retnaln$of tits Deceased,are recovered from the cremation chaml7er,they tTAao be Reparated
from the cheated remains of the Deceased and disposed of by Use Crematory.
5, Me here y authorize the Crematory,to separate and remove from the cretnattotl citarnber all nancatnbustiblematerials,ipcluding,
but not ii ted to,hingep,latches,nulls,,jewelry and precious metals,and to dispose of such material$.
G. TQI( rrin emation,the cremated remains of the Deceased,consist rn ohe conteltre�oP�ne fragments,tvill be tnecl*aoicall}p�tverixed
to an un ntiftable catt.9istettey prior to placement
„ , ., ,.-. .-ww,w:nn. r..ln.t.lsA.r eMir.n.�nf iS,»rrYftasrd.the t:rematory will place tl,e cremated retuafnw of The DredaSed in A
01, 1 200- 00: 51 703-64403297 '_A J r6TER ELEMENTARY F"GE 02
dl/15/10L9 09; 33 518-792-1237 BEGAN&DENNY #1346 PAGE 01
12;1 a a08=594j10 _ HOMESTEAD NERRlCK f'Hut "u�
rattlale+rr � 1cfi i►not�ailfgnW4!bs n;;;type of atiivblent, "
to the Ave t »ern�r c4t+taUn*r is 1t,elnlT}dent t1+wmetlteMd to Rp of ttie pemated oteoai"I of the eceased,ttny czeess�ramattd
ttarxEns+ a!I b*p'.acm In a eeeottdar)cvr+t�irutr A. rtturote is the Funerel Home.,Its6thtf week t t prirnaRy ura ar cnotateor.
Z�bVQ qqd Kd an0 at ow}rd�s,thNt seen�Ith the turetao or raasotsAtrle care s�tAe aae er the Crornator9'c beat"attOrt6,it is
not pos a to retcprro� aqf isartk[AR of the ccematN remsla►of thx Dwetasad,End at eoms Art}Glee clay ina�d•ertentt become
7tr c rst r wretttfatq;C1 � i h«t Ucreffatf ze 1hriCr rn�tory t�di.9po of Nny sv�r},n+R Ideal parWor k}ctes ier is�anY1laRitul'Papnnrr tt
ticttti a prlale.
0. t4fltds I/ Q Ice a ecilic.v�tttt�ert irt9tt'taettans in thie,�.etl+rrrltatfun,the erematien proco�ng and diapusitiott ofthe remains of tbr.
Mceoae4 ttvt 1>r ""fumed 1n amedout with u+>'Part rel,tgious nr a arc cvttArre.
1t. Aq thec.e�+ ht by
era n u�rtstrtl�ie addr l((es)in tested below tJ(Wi gr c IN't eriod of 30 Isrthelh�HAt the cre me 3 rqodl df Jos of thx
pr►Nrx to ' t� Ipnlsa
1;at eased tort ttpctn Wr a Denied of 124 dove afar thn date sdch svrtthN notJrattQnllmasn� 1thmayde m appropriotte arirxd
and dfr a t0 dispose to rtted crort aW remains or the Dit"ased In any Isww••fra
l2, ar4i a sdre u f�Isttrnnfry,reRosea and hole ttte Crematory Funeral Home,their aRliatel,agents,erttplolvtoo spd ass9dns,�hsrmttas
{�onis any dell bed,dn��►�g t U bltlty A' caul&%of t+c la�(taefvtilnt attor►teys'he+an tAPCnsts o At�afloe))an eogn��tion
th!crrt ar I dt oaltlao or t e cremated reenatoa vt the lyeceASFtl,es NvtMnrt�Qa hitre}n,or ntyy,Otte fe�lnro to uorrcctty adrntifr
the rexta of the 0otased,d6cfose the prtarnee o1111�4w �1pla>wfar! +nrchanlcal or radiaocttve lfevtcea,or take potstytan of,b*
M410 per "cut arraltrtr»tnis froor,for drapositit�n a suo reana}r�•
Ls. except tuc t torch in WSAutaor4iatlon,no wsrrn+,tiv,as pressed or Impl}ed,art made.br the(Funeral Hotae,Crematory,IgF any of
yWeb•rtssp Wa affiliates,scan%cr ttttptvyast•
14. j, cis n oat l n$ OTpftttth�ie Ru��toeer gHoe<►a,t eapay of the bookllvtv and et a tittsd"Cm"istton actell$&Mltai+a�ido 4didotiai
4xpuvs tatntmadvo 4 Wt that txenratloe process MATION AND DISPOSMON
SI -ATURE OF PERSONS)AUTHORIZING CIR
Me warrant tat oil; rrrpetat7t�tati4+►t am atatattrents r"de tan'ettt art tr4sttd c?rtatt,and that I*c lave rt*d arld tlKdet+rtaed the
pKa+ iptw con .or in this dpvmwnt,atld tAat Iwq)ww rerrhed the ritwllltt e�ntftt.d +( rtrna4ott WWI,
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