Andrews, Margaret TORN OF QUEEVBUr�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name ( P Ro-)4��I n4( gl�`7 Case# 2--
Date Of Cremation
Time Cremation Started Y-4 /q-,
Time Cremation Completed
Type of Container Gb4,1_,?,td __001 tZ ,/� ✓{ (� �
Remarks
32
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TOWN OF OUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone t518) Crematorium 745-4477 (if no answer)
Cemetery 745-4476
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crernatonurn. in accordance with and subject
to its Rules and Regulations to cremate the rernains of:
(NA ) (SEX)
(STREET) (CITY) (STATE) (ZIP CODE)
20
who died on r day of iA0.4
at � Sv
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
--
Relationship to deceased —M
Name of Funeral Home
IMPORTANT
I represent that to the best of my knowledge, the deceased has or h_s no p emaker 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)
i
l� A
/1 (SIGNATURE OF ,RELAY E OR LEGAL REP. AND ADDRESS)
Signed on this date:
SINGLETON»HFrA.IX FUNERAL HOME
Q
(319)793-"59
4r
r "Customer's Designation of Intentions"
Name of Deceased: ' `1``
Cremation: ` ��s. _ c OD
(Scheduled.Date)
(Location)
Manner of Disposition of Cremated Remains:
4,.
❑ Burial at Return to Family
❑ Entombment at ❑ Other (specify):
I hereby designate the Disposition of Cremated.Remains and acknowledge receipt of a copy of
this form.
x
(Signature)
` 47
w:•, 1
(Printed Name) (Relationship to Deceased)
(Address) Y
a.
(Telephone Number)
"Cremated. Remains which shall not have been claimed. within 120 clays from the date of
cremation may be disposed of by this firm by placement in a columbarium."
r�:.�'�-_.
Printed Nam of Funeral Director Signa Funeral Director Date
or Undertaker or Undertaker
TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF CREMATED REMAINS
Cremation:
(Actual Date) (Location of Crematory)
;I,.. Disposition of Cremated Remains:
(Manner of Disposition)
(Location)
(Date)
Name of Person Making Disposition Signature Date
#9 WHLTE:Funeral Home Copy YELLOW:Family Copy PINK.Crematory Copy CUSMTEN Rev.V96
�� AUTHORIZATI�. tA'OR U"MATION AND DISPOSITION �r )
:y �!-"� 031 Rev.4P98
NOTICE:THIS IS A LEGAL DOCUMENT.IT CONTAINS IMPORTANT;PROVISIONS CONCERNING CREMATION.
CREMATION IS IRREVERSIBLE AND FINAL.READ T `HISS DOCUMENT CAREFULLY BEFORE SIGNING.
I/We,the undersigned,certify,warrant and represent that Uwe have 'the full
Priority mg right
*uthority,and know of no living pefson who has a superior
P y right under state law,to authorize the cremation,processing and ,r,
(hereinafter referred to as the"Deceased" disposition of the remains of S � r • --
�+ •�_ j
)• _ name or21
uer
Date of Death
y request and authorize _�- - E
I/We hereby ��; .;, Time of Death ❑ P.M.A.M.
�_ l : 'r � �-�;;!'r,
nme te
(hereinafter re` ferred to as the "Funeral Home")to take
possession of and make arrangements for the cremation of the remains of at 4--'k ��_. `�%t'' t. )
(hereinafter referred to as the"Crematory").
ame o rematory
I/We hereby authorize the Crematory to return the cremated remains of the deceased to the possession and custody of the Funeral Home.
I/We understand that the services and obligations of the Crematory shall be f dulled when the cremated remains of the deceased are returned to the
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:
H required? ❑Yes X No Describe
Description of urn of container selected: i L Suitable for shipping: ❑ Yes ❑No
❑ Deliver to
c . _ ame Cemetery
Release to family �1�,C. c a t_ ,C A
❑ Scattering at sea by Funeral Home or Funeral Home's a am ReWve reran mans
❑ Ship via U.S.Registered Mail*
To:Name Address
❑ Other
*Funeral Home and Crematory are not responsible fOr any loss or damage of cremated remains shi via `
PPS Registered Mail with United States
Postal Service.
The cremation,processing and disposition of the remains of the Deceased authorized herein shall be pperformed in accordance with
all governing laws,the rules,regulations and policies of the Crematory and Funeral-Home,and the following terms and conditions:
1. 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 censtructed.of metal,fiberglass,or other noncombustible materials,
Uwe 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 ofzthe Deceased
prior to cremation, and'dingo uch items at its discretion. WE HEREBY CERTIFY THAT THE REMAINS OF THE
DECEASED DO ❑ DON NTAIN ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE.
Pleaseinit e.
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:
DaKr*dm of impbnted Devke nlepWtioo
Description of Implanted Device Disposition
• p`"'^`""' 'v n.s dig osed of at the discretion of the Funeral Home.
3. The cremation container containing the remains of the Decease wI e p ace m e c0vm WWI 'If
irreversibly,destroyed by prolonged exposure to.intense heat and direct flame.I/ I e 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,inchidmg but not limited to body prostheses,dentures,dental bridgework,dental fillings,jewe�and other personal
articles accompan ing tie remains of the Weceased,may.be destroyed during the cremation process.I/We 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 icy 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
remains will be placed in-a secondary container and returned to the Funeral Home,together with the primary urn or container.