Squires, Maude 70T11N OF QUEEVBWU
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director ���
Name �� I y �t✓ t Case#
Date Of Cremation ,2 3
Time Cremation Started '
Time Cremation Completed r3 C l
Type of Container JNTz� oo4q-� CU,►.�� /Vt
Remarks
c JAG_ 4/1
. 15- i'
TOWN OF QUEENSBURY
PINE VIEW CEMETCRY &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:
(Name) 6 (Sex)
l� ) z,?L) '1
(Street)m Y' (City) (State) (zip)
who died on day of 20 a-3
at
(Place) (Address)
Name and address of nearest relative or name of person Authorizing cremation:
L7 Y2 2 � 4-
(Name) (Address)
Relationphjp.to the deceased
Name of Funeral Home
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or has no 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 o sa remains as directed, whether such claims or demands are or are not
wholly groundless, false ra ul nt.
(Witn s) Address)
nature of Relative or Legal Rep. and Address))
Signe this date: `2
031 Rev.498
/� l
AUTHORIZATION FOR CREMATION AND DISPOSITION
NOTICE:THIS IS A LEGAL DOCUMENT.IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION.
CREMATION IS IRREVERSIBLE AND FINAL.READ THIS DOCUMENT CAREFULLY BEFORE SIGNING.
I/We,the undersigned,certify,warrant and represent that Uwe have the full legal right and authority,and know of no living person who has a superior
priority right under state law,to authorize the cremation,processing and disposition of the remains of
ame o ece
(hereinafter referred to as the"Deceased").
Date of Death ) r Time of Death A.M. P.M.
I/We hereby request and authorize (hereinafter referred to as the "Funeral Home")to take
Name o unera ome �nn
possession of and make arrangements for the cremation of the remains of the Deceased at b" V i ,a r C Yr�r �r
o _C
(hereinafter referred to as the"Crematory"). ame y
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 fulfilled 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:
Is$pecial handling required? Yes __ Is Describe
Description of urn or container selected: Suitable for shipping: Yes No
Deliver to Cemetery
ame and Address Ot Cemetery
7] Release to family
ame o esignate amp y em r to ecerve tamale emains
-: Scattering at sea by Funeral Home or Funeral Home's agent
Ship via U.S.Registered Mail*
To:Name Address
F-J 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:
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 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 ofthe 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 XICONTAIN ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE.
Please initial o 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:
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.
4. Certain items,including,but not limited to body prostheses,dentures,dental bridgework,dental fillings jewelry,and other personal
articles accompanying the remains of the beceased,may be destroyed during the cremation process.I/we further authorize that it
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.
S. 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.
o I/WP unrdvrctnini d and aeknnwledge.that even with the exercise of reasonable care and the use of the Crematory's best efforts,it h
"Customer's Designation of Intentions"
Name of Deceased:
Cremation:
(Scheduled Date) (Location)
Manner of Disposition of Cremains:
Burial at Return to(Specify person to receive cremains)
Entombment at
Other(specify):
I hereby designate the Disposition of Cremains and acknowledge receipt of a copy of this form.
k-
(Signature),/'
(Printed'lame) —relationship to Deceased)
-(Address)
(Telephone Number)
"Cremains which shall not have been claimed within 120 days from the date of cremation may be disposed of by this
firm,in the following manner of disposition
Printed Name 4-Funeral Director Sig Lure of pnneral Director 7"Bate
or Undertaker or Undertaker
TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF REMAINS
Cremation:
(Actual Date) (Location of Crematory)
Disposition of Cremains:
(Manner of Disposition)
(Location)
(Date)
Name of Person Making Disposition Signature Date
I hereby acknowledge that on
Date
I took possession of the cremains of
(NAME OF DECEASED)
(SIGNATURE) (NAME OF PERSON RECEIVING CREMAINS)
White copy to family upon initial arrangement— Yellow copy to Funeral Home— Pink copy to family upon disposition
AP 27—REV 10/96