Macewan, William TOWN OF QUEEVBU9�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name l i"I AIA T NigC'(= IJA I'� Case# ��(r
Date Of Cremation 3 - moo - zc�3
Time Cremation Started D 16 A-/--I
Time Cremation Completed CA , b Q A-2t
Type of Container P50 a q-C) Got - J11 -4 � N
Remarks
C7R/1-i
_ ) S A_/►
3
TOWN OF QUEENSSURY
PINE VIEW CEMETERY&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) (Sex)
_ M FAwt1 RL), CANSt.Voor2 A 14dk
(Street) (City) (State) (zip)
who died on J 7 day of relit kcw 20 a
at
(Place) (Address)
Name and address of nearest relative or name of person Authorizing cremation:
_ �1[5V6'A! 1t�1�</1'nCCc ZR- LAWN i2�, ��Ar�t�t=1/�?!2f 1��►
(Name) (Address)
Relationphip.to the deceased S 1 t5ps6d
Name of Funeral Hom DE Kf\f�L
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 of said remains as directed, whether such claims or demands are or are not
wholly groundless, false or fraudulent.
(Witness) (Address)
_A�� 6. " " 29
(Signature of Relative or L I Rep. and Address))
Signed on this date: i
"Customer's Designation of Intentions"
Name of Deceased: �'�(�;/ + ;. t L ►hC.L:.W A 14
Cremation: :3 fez'I jj.,/c 1,'r 'w<t '_ c
(Scheduled Date) (Location)
Manner of Disposition of Cremains:
'�Kl -
[ ] Burial at [ ] Return to(Specify person to receive cremains)
[ ] Entombment at 4:41c=r�E 1 ` _'!` a h/G
[ ] Other(specify):
I hereby desxgitate the Dispositioh of Cremains and acknowledge receipt of a copy of this form.
/ /9 ,
(Signature) ' _
S1t3VL=d Nall r ! / q h' r,�l
-A..Printed Name) (Relationship to Deceased)
`(Address)
A(.
(Telephone Number)
"Cremaini which hall not have bon claimed within 120 days from the date of cremation may be disposed of by this
firm,in following manner of disposition
IL
Printed Name of Funeral DiiVctor Signature of Fun Director Date
or Undertaker ' or Und er
f.
T,,,BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF REMAINS
Cremation:
(Actual Date) `. (Location of Crematory)
Disposition of CremainC--
(Manner of Disposition)
I
(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)
F PERSON RECEIVING CREMAINS
(SIGNATURE) (NAME O )
White copy to family upon initial arrangement— Yellow copy to Funeral Home— Pink copy to family upon disposition
AP 27—REV 10/96
,
E'3:":t7!20tJ3 i).:i5 °IS-792-125� RE'a.1N2r><'alt'.' RLo"4i? part: �
received y tbC Crtm:ltor,, in a casket ter otlier co„taintlr Constructed of metal,ail?ergiass,or other iiuncombitAtEhlc fnLterL2::,
1lweaath Itethe remains of the Nceastd to be remdvt.d prior to gemation and placed;It a combustible crernatitte+container.
I/We Net at authorize the Vitutral Home or Crematory to make cusposition of any such noncombustible casket in arty tarcrui
msrtnea deem$approrpr12te.
Mecban'• or radinactiv< device nlasted to the relmslas of the Deceased(f)e;h as pa+:e.utu;:e:x.ote.1 MAL cr.-lap-bets pia ed.It the craru:tiu+, w. 'The Crtmatory "III not cremate rno human remains witici cttritain stl_ r uc of
im state aoeebaoieai or radi4-e. ,levict. In the event the retuatus of the beceased coutaih x„ch a de,let. bete rerpht
aufborize R Funeral Home,its ind employees,to remove an�Y such race1�,nical dtv'scen frcm the rc,naitw nt ihr.I}reryrrtt
prior to tsatiaar and dispnV- :.:h items At its discretion.Ill R HRREBY CERTIFY THAT THE REMAINS OF ThE
1]RCCAS D DO au'wU'[ Xl i:ONTAIN ANY TYPE Cll'iiMPLAN I P:U MECHANIC AL tilt R:u)WAC'il1 r,ilc%It c.
Please initial one.
Listed 'are all Implanted mechanical and radioactive devices which the Ethers: Haute If-outhorizett to rertiuve from the
retrains o efts Dccta:ad Prior to cr ettation,and dispose of as indicated:
ftwipb.R.r r—n� --— --- -- -- a`I wR -- _ ---- — ------
If no}pair a for disposition is given,such items stay be.disposed of at the diceretio,e or the l',tnrr ai Honer.
i, The cramifion container conlaining the rowaitts of the Deceased will be piss d in the cremation cttatnber and will b'n:t.ely and
Irrewersl destroyed by prolonged esposure to intense:hest and direyt flame.ef, 'e authnt iae the Crett,ator•y to optin the cremation
chamber urine the cremation process and reposition the!remains a(the ffecPesed in twdt� t„;r<ciiitotr:+cumpl:tt .,:n .horougtl
er"RA
I. Certain i including,but not limited to body prostheses,dentures,dental tar idgewt,rk,dorital tli:tnIV 'eweiry,And oft e: i rrwna!
articLes.s fw
yaig iiit remains of the deceased,maybe destroyed during the cremattaci process.i'We further autborI•re t.}at+r
Gal ire han the cremated remains of the Deceased,are recovered from the cretrtateun chamber,the!'may be separated
thiett the rentaiits of the Deceased atld disposed ofby the Cretrtawly.
)/WettestrtZethut.CrPrnatorytoseparoteandremovefromthecreniationcitainberltlmtnotmitwitiblemater;nl%.4:n:audin;,
but not 1; hinge,+,ketches,nalls,jewelry and preciot it metals,and to dispose of a:tcb intaterial,g.
e. Fellowred
Ion,the:cremated remains of the Deceased,con0sting pr rt;Let,,if bona fr•jc ntc.r i;,trill be nit.chantcalh�miveriztd
to an uable cutuislraey prior. to placenielit In an um or other container.
Unlessat container suitable for Shipment is purchased,the Crematory twill place the cremated remains of the Pectai+sed it;a
contaih Is not designated for any type of shipment.
In the e urn or con(.ab,tr is insufficient to accommodate all of the cramittid reiRaim or the 1)4teased,any excess crt•nint'
remaine piaccd in a secondary container and returned to the Funeral Row.togethet ailh the primary urn or container.ed
VMwe and and acknowledge,that even with the exercise of reasonable care And the u,e of the Crematory's bt-at efforts.it inot po recover all partic es of the cremated retrains of the Dect:aved,and that some particles tttav ittadvertt•utly became:cotminith particles of other cremated retnsht�}remainin in the crotnationchamber and4,r other devices utilized to process
the creromithis. I;Wie hereby authorize the'Crematory is disprvte of any such re.idual particles In any iswiv, re:nncr it
stews riate.Unksttve specific writiett in,tructions in this Authorization,the cremation,proccs•ti}+S;•nd ditpusititra of the rhos+,u.of tier
Deetrtesedwf npt be performed In accordance with any particular religious or ethnic custotits.
11. In the t tilt et*cnAItd remains of the Deceased remain utaclaimed far a period 14 3tI days,tees Funeral Home sheIt glee written
notice to us by certificri mail at the atidrees(es)indicated.heiorl, !`11'c ai;rce ileac in'tltt ev,,4, tilt cic,m, a rtr:..::.
Deeeasal et Lisclaimed,l'or a period*1120day's artrr ilm date such ArltIvii tiourieatititi is IT advd,flit P'uoer9l
and citric to dkpost of the wiclaimed cremated remains of the Deceased In any lawful raw nner it ma;deenit appr-print$.
12, Me egre to indemnity,release and hold the Crematory,Funeral Home,their stiliates.agents,cmpptoveea and astlpns.t arn:ks,
in.an* nd all loss,daneagev,liabltitror causes of action(Including attNrneya'net 'and e.xpet:,:,uS iitlQaticnl in teyaectii;u with
the cream toil tad disposition of the cremated remaino of the Dretasetl,as auf.hr.rized h}rrin,or ru rout tailor r{o cnrrecti+ irtrntify
the Tema, tti*tha[)pooh-ed,disclose the presence of an im fired mtthrnirai n. r„ti„„i tiwe$$Cott ef.or rake poasesr.'enn Ur or
make per sent arrangements for,the disposition of suet re�itaihs.
U. Except as forth in this Authorization,no warranties,expressed or implied,are made by the runt.-rat dome.Cremator,-.or w, of
their affiliates,agent-A,or employees.
lA, MWe and stand that this doeVwent doe;nat canton a complete and detailed desert$,tint;of e,e r r:,meet of flu er:•en>,et„n p .MD,s.
UVtro will owlefte receiving,hour, the Funeral Honte,a copy Of the booklet entitled "C.reinstiur acts', cutitauting xtiditlottat
e Y 14f4matioo about the cremation process.
si NNIVRE OF PEASON(S)A[irlhllUkUZ►NU CREMXFION AND Disposer o
VWo vwt•aut hat all representations sod statements made herein are true and rortert,and that Ihs•n hate rrod and unttRrs,-wo tat•
provisions coo. in thin domateat,and that L'we have necelved ti►e br>oltlet antfti,;d"Oemation Forts".
IN
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WITIS.S ,M,104
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.0 ao Uu U:J. Ula H11,KMHf9 JUHm1bUN& b1MMUND5 865-219-7793 P. 3
��•iw�au� AG:D" D1 y-1-1-11bi RFGAN&�NNY 01346
rttCeived the C)t•ethatom Paces (�.3
live gat the r Y 1e a tuLet or otht:r coutaitwr c_0 zimcled of Instal, arelaa or other a+�ncotnbt�rtible mi�tei tnfe,
I/We tart er sathar�i a FernKal Boe�or crcm* ��'� � n lad placed to x tambastt!�te creto$tian en�rtatincr.
marxuer i deems,appropriate. 111W9tvn Of J spelt tmomwamnbtiatible casket to Any lavrNul
• Meal of radioactive devlCr ',.,plaltted ifs a remai"Qf-the DOCeezed(such as pacemakers,etc.)mar create a Nuard
,'base t, 1*0 erematloa rr. ,t?er.The CmbmsE�wW +� h
"' �'� thaaftat►t ridioaa de►icx,]p Ike event gotei+emate sA hum remains whac contain any type of
a ork o f'Fuutral Home;Its n em (o tool:mreeoAriaa of the d contain such a device We heeeb
p Jm ib ra,ae.e ouch moc"Alcal devil"from the restates or the Dectesto
prior tq, ettaattolt,'atid ti es b items at its diseratioaa. 11IMEBY CERTIFY TRAT'TIM Jt,8MfjNs bF 1<RE
DECkA' D DQ 0 DO NOT X CONTAIN ANY Tyn QF IMPl.AMi1 MECHANICAi OR.RADIOAC'nv.4 DEVICE.
Listefireft
Cease initiei one.
Tema b sit imp1acted atevbanical and radioactive devim which the FORM) ldoine iv authorized to renwve
reran tt, I)ecaageprior to asmation,and dtopon etas i»aicated: from the
PbwAw
u no tioe ror dlepwslttou is given,suck Stems Wray be dtapooed of at tote diserettne of thi Funeral Hoenre.
;. The er tics toataincr uontaiami the rexaains of okrasou
memrrxmma�jn3
will be placed In tlx cremation chxmbcr artd,rr'R be toto�y end
irrcrsret. tleatr"td by proloage1efiporeareto i ifftt flame.Me nothorire the cremahrry to a the 0rcmaa and
cAatls;bor, uring she creAtarfon Frooees a>!ti t�pc�tof tiro Doceated to order to facilitate a complete and ttaoroagb
i, Cads w it raps,iocludin lsot rsot)nnited to i.b�o�d�y��prosthet es,deatar�deMAI br9dttewortaideP fitmin0_ieweiry,and other perpptiaii
�_} °reaaaixne of else s+ece fd,shay be tro depict craw crown'on roeeft a tariher aurharltc that It
taAa the crcmmuttetf rent of else ble ars t'e�owrad ftoaz the cremation cbma lber,they duty be separated
&wu th+t • mtmued remalaa of Wt Deeeaeed stud d y tlm�t(:r+itntatory.
�.. l/Wehere satthortxe time t;retamtocy to sepltrate and txnaove lhom the cm+wasiioe ehantber all monoorubustible tamattriais,inctadingo
but oo!l ttd try p3nttag,!aleamaa coatis.Jex elrY and pr aclpas at•inls,stud to dlepoae of sawh mxlerWs.
Fotlowin tbie cremated m emaino pitthe Deceaased, OptJ�pg pfititarily 4F bone rragtmments,*M be mechaaicstly pulverized to sot up idols cacebtsu►e7 Rxfiogr to pl+lecmnemat la in tuft or outer rnnfaMes. •
1• Unioncontainer
amt cis a conWlter suitable for obi1rtatct is ptrsehas4 tb;Cremteatory Nil)piacs the cremated remain of time Deceaased in�;
conttdner imdeh is riot designated for any Me ofAk#ffxaL
<. lu the eV We tore or coWalner is ((f�insu t to acrnntpsottrUR all oft �xun.tsd"duin3 of the Deceased,any excess crmntcd
remains iQ be piecrnd lean oeeoadary c6ttiaber and returned to iha aFv,,r, ,!Rome,together with the prionary am or container.
'f: llWe aft d sad ackpawied t,t�1�seem withtye exercise n!r✓ taab9• ,
Kvt to recover all t�n(!ht'CitYtlOnWdd ire sad ties uea of the Cremrttory a boa£ai1'o�-taf,it is
i� eettsaitte of tbo Dc� z�3 bed tDat samm�e s may laadwcrtentlq become coaaialmt w1t�'ppem'tle���f otk,�-cm'cmetad In the�-, tu��Ioa gt�er ao�er doyiaae u3iFaed fA Pt•OCbSC tic. d i'emaint;.uWa harebr authar�e the retle4tory diapper of and oo�ah residual psrticloa;n any lawlui ttiaaaer it
dweaime.�i • late,
to.. Vulvas V e ve spccutmc written imstractioanr ifs thi.,Anthoti>fatioa,tote cremation,pracxsming and dL1kpo6ition of the remains or the
Deceased apt he perforyttet in accordance with arty parttaular teaglour or ettsaic awsbnts.
1]: In the eve the cremated remai of the Dtcras>ied remain aAclafsaed trot a period of 30 days,the 6unrxad#tome shall give writtcu
npttq:to dus by cerdoed wall at the�d tirWie(es) tnAicot"Wow a agree that In the twat the arjuAtri nt:miJ13 of the
T►� . axin tr�aclalnay for a< od o[!�Q days a(fer tote die such wzttten rmatEt'tratien is maiTetttthe Funeral Fiotoz is mtuthorized
and too.dielro; of le aadaitned rf twgagtcd reAat►naaot;tko 1lkoesei d lst bar lawtxF rsltit nor tt may deem approlwiste,
i�- V'e q tolAdewoir reiesae a* tratd sofa Ca+ematttoRy ,FnAOTit klomoa their aPAtiate8 ants,obiptoyees sad aet;ign:;,•bermml4A
traac•aAy d a1l ' ages,liah[by or aesof ae ' (i estates ya'tbes attdexpeneee of tit lion)to gonaecttaa wttb
tat creipw tok artd tYllip don d the eremam irta�a{Ao o('tts♦ aR>lu ortaQd iiereimm,or my/otrc fa[tslre to correctly iladf'
the reTnid or tote Deaeaeedo dtacIoae thep se of sit t acccbaakai a radiomtcti•e devi etr,.or wke posseiswn or,or
make t WAIT ctments for,the dl9pcxi of to retimaltts.
Areept as t Mrsj�in this Auetborirxtion,no aarrac►tier,sttpressed or ttt+plitd,are made by the Funeral Home,crenmatory,or any of
their reap Hive$}llWAex,agents,or aotydoyem
lA. LWe 01 land that this doccyyimacut does riot cvatain a tam left and de laikd dtscri do of vm aspect of the crentatioa process.
nob" ra�t�ioava.,t urbthe the h oil apt How a�y of the booklet estttlad '�Creosatton Fatcta" coutAiniu>z a dittonvI
S>G NATCRE OF PFAWN(S)AtUC'. OIUZING CREMATION AND DISPOSITION
11�Ya warrant tag represe itittlons gad statftrmts made herein are true and correct,and that Vwe have read and uudereiaad the
iorvtiisuom con ed!mx dole aoeumatr,and that Vwe have rudved ON booklet ranted"Cremation Facts".
kddratc ; �i' c, {'✓in4 S KL.� (ti�UkUl fr{rN ?�r.{ '1e1.Na(� )_ S
RM .,,, •r.Taio.n,p,.� poca,es`^�'
Address
two
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WITN'M_ Y •wmw* Date. ,
arne..T M. ,w
1trJe 9CI Mktlyertwnt LP.