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Miller, William TPON oY QUEENfBURY PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director Name W ► Lb P,A c M � �,IX,9. Case# � L, Date Of Cremation - 1-2— Time Cremation Started Time Cremation Completed Type of C o n t a i n e r C"\ Remarks TOWN OF QUEENSBURY L/ PINE VIEW CEMETERY CREMATORIUM , 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 Cteinatonum. in accordance with and subject to its Rules and Regul ion to cremate the remains of: (NAME) (SEX) Va� I Z� ( TREET) (CITY) STATE) (ZIP CODE) who died on day of r l 7 206 -1 at �l��h ✓ (PLACE) (ADDRESS) Name andaddress of nearest living relative or name of person \authorizing cremation: Relationship to deceased Name of Funeral Home2J" �67-\ �( VtVTT+A� O k 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 em by eason of or connected with the cremation of said remains as irected, whether such c i or ema are or are not wh ly grou le s, false frauudduullent o4t1 ITNESS) (ADDRESS) (SIGNATURE OF RELA E OR LEGAL REP. AND ADDRESS) Signed on this date: r e�• Z 0�`4 AUTHORIZATION FOR CREMATION AND DISPOSITION 031Rev.4/98 N I E: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 Vwe have the full legal right and authority,and know of no Irv`in/g person who has a superior priority right under state law,to authorize the cremation,processing and disposition of the remains of 'Name or o eceased C� (hereinafter referred to as the"Deceased"). Date of De ,h�,�-�/ Z�� Time of Death ��. A.M. P.M. I/We hereby request and authorize IS(,��ll vA,4 (hereinafter referred to as the "Funeral Home")to take ameo Funera ome ,V/e� possession of and make arrangements for the cremation of the remains of the Deceased at s/he ameo rematory (hereinafter referred to as the"Crematory"). 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 special handling required? Yes _ Io Describe Description of urn or container selected: Suitable for shipping: Yes - No Cemetery Deliver to _---`` � ame an Address o Cemetery i�'Kelease to family �11[ Name —signaled Family Member to Receive Cremated Kemams Scattering at sea by Funeral Home or Funeral Home's agent `l Ship via U.S.Registered Mail* To:Name Address 11 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 of the 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 _ 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 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 ewelry,and other personal articles accompanying the remains of the beceased,may be destroyed during the cremation process.Ie further authorize that i1 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 herebl 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 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 cremate( remains will be placed in a secondary container and returned to the Funeral Home,together with the primary urn or container. _­ ____ __.r aa.,.....,.,.F H,-!` .—if-0c hnct Pffnrtc_it i-