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Carpenter, Alfreda TORN OF QUEEVBURY PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director Name ►��.-1'R�d'Ac F C�Al2Q•i��►,�- lZ Case# 2 Date Of Cremation s [0 — 2,60 3 Time Cremation Started d Time Cremation Completed 3 �� ✓� Type of Containery�4z����2� �, _ Remarks TOWN OF QUEENSBURY PINE VIEW CEMETERY CREMATORIUM Quaker Road. Queensbury, New York 12804 Phone (518) Crematorium 745-4477 (if no answer) Cemetery 745-44.76 AUTHORIZATION TO CREMATE The undersigned requests and authorizes Pine View Ciematonum. it) accordance with and subject to its Rules and Regulations to cremate the remains of: AME) (SEX) ,2dG . STREET) (CITY) (STATE) (ZIP CODE) who died on / day of 20ejr at 4� ` (PLACE) (ADDRESS) Name and address of nearest living relative or name of person authorizing cremation: Z, a 23 7 �, Z 1!/.z�7i Relationship to deceased - 1 Name of Funeral IMPORTANT I represent that to the best of my knowledge, the deceased has(r 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 of said remains as directed, whether suc laims or dem ds are or are not wholly groundless, false or fraudulent. -- ESS) DR S) j (SIGNATURE OF RELATIVE OR LEGAL REP. AND ADDRESS) Signed on this date: --- �� I I ' I I I P vv AUTHORIZATION FOR CREMATION AND DISPOSITION 1� 031 Rev.4/98 �v�`' 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 Vwe 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 (hereinafter referred to as the"Deceased"). a o ecease Date of Death Time of Death /2—3ro A.M. o(P.M. I/We hereby request and authorize (hereinafter referred to as the "Funeral Home")to take same of Funeralome possession of and make arrangements for the cremation of the remains of the Deceased at ame o 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 KNo Describe Description of urn or container selected: Suitable for shipping: Yes No Deliver to Cemetery ame and Address ot Cemetery Release to family ame o es,gnat amp y Member to Receive Cremated Remains -. Scattering at sea by Funeral Home or Funeral Home's agent 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 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 an 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. i 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 j 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 Deceased,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 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. 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. 1 9_ I/We understand and acknowledge.that even with the exercise of reasonable care and the use of the Crematory's best efforts,it h� l2 � "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 o remains and acknowl gZrept of a copy of this form. i� (Signature) (Printed Name) (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 of Funeral Director Signat e o Funeral Director Date 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 ,k National Cremation® • S E R V I C E Tuesday, March 04, 2003 Pine View Crematory 21 Quaker Road Queensbury, New York 12801 Re: Alfreda Knapp Carpenter Mike: Sullivan- Minahan & Potter Funeral Home will be bringing Alfreda Knapp Carpenter for Cremation. Enclosed, please find ch ck for cremation charges. Th you,an Charles F. Hollis 1105 West Genesee St Syracuse,NY 13204 (315)471-0097 • Fax(315)475-0667 Toll Free(877)627-6326