Huntley, Donald ro WN OF QUEEVBU9�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director ,5j r,J& .F--tyT,�.
Name -Do-o At-) (j Case# 9 ��
Date Of Cremation 3 7 'A -
Time Cremation Started g =2 S
Time Cremation Completed
Type of ContainerGt4)g� 'ZoqQ-d M 9 30
Remarks
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AUTHORIZATION FOR CREMATION AND DISPOSITION osiRe,.a/s
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 i
Name or -✓
(hereinafter referred to as the"Deceased").
Date of Death A i `.- L "D ' Time of Death ❑ A.M. q P.M.
I/We hereby request and authorize :s k't �L V� (-'.fx (hereinafter referred to as the "Funeral Home")to take
possession of and make arrangements for the cremation of the remainsa Deceased at
(hereinafter referred to as the"Crematory"). amen 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 fulfilled when the cremated remains of the deceased are returned to the
possession and custody of the Funeral Home.I/We hereby adthorize the Funeral Home to arrange for the disposition of the cremated remains of the
Deceased as follows:
Is special handling required? ❑Yes )�No Describe
Description of urn or container selected: Suitable for shipping: Yes n No
❑ Deliver to Cemetery
e ry
)<Release to family U14 - 6�
ame of Den randly Member to eadvZ ns
❑ 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 Funerai 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 Crematerry-is.antheriaed 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,
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 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 RADIOACT;VE DEVICE.
Please initial one.
Listed below are all implanted mechanical.and radioactive dievices 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
— Disposition 'If no instruction for disposition is given,such items may be disposed of at ate discretion of the Funeral Nome.
3. The cremation container containing the remains of the will-be placed in the cremation chamber and will be totally and
irretersibly destroyed by prolonged exposure to intense heat 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,includin but not limited to bo ro5theses,dentures,dental bridgework,dental fillings, and other personal
articles accompanying111 a remains of the De s�yed duringthe cremation process.I/We further authorize that if
any items;other than the creina reitiaiiis pre renaveredgfi otn Elie cremation chamber,they may he.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 pros metals,and to dispose of such materials.
6. Following cremation,the cremated remains of the Deceas�,eonsisting primarily of bone fragments,will be mechanically pulverized)
to an unidentifiable consistency prior to placemenfin aTn 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 cremated
remains will be placed'in a secondary container and returned to the Funeral Home,together with the primary urn or container.
n 1rM7-'1 .nAo +.-A.-A—IrnnwI.A. *hat pupa With the exer ofreasonable care and the use of the Crematory's best efforts,it ii
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SINGLETON-ME"Y FINI.A"HOMIE
4W Bay Vzod
Qu sb"y.NY 12W >
(518)793-""
"Customer's Designation of Intentions"
Name of Deceased.:
Cremation:
(Scheduled Date) (Location)
Manner of Disposition of Cremated. Remains:
❑ 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.
—�
(Signatae)
(Printed Name) (Relationship to Deceased)
(Address)
(Telephone Number)
"Cremated. Remains which shall not have been claimed. within 120 days from the date of
cremation may be disposed of by this firm b placement in a columbarium."
Printed N_ a of Funeral Director Signatu of Funeral Director ate
or Undertaker or Undertaker
TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF CREMATED REMAINS
I
Cremation:
(Actual Date) (Location of Crematory)
I
Disposition of Cremated. Remains:
(Manner of Disposition)
(Location)
(Date)
I
Name of Person Making Disposition Signature Date
#9 WHrM:Funeral Home Copy YELLOW:Family Copy PINK:Crematory Copy CUSINTEN Rev.4/96
TOWN OF OUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road. Queensbury, New York 12804
Phone t518) Crematorium 745-4477 (if no answer)
Cemetery 745-44.76
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:
a�,e__
(NAME) (SEX)
c
(STREET) (CITY) J k (ST TE) (ZIP CODE)
who died on \ day of UL(c_k 20
at
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
J
Relationship to deceased
Name of Funeral Home
IMPORTANT
I represent that to the best of my knowledge, the deceased has r has 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)
(SIGNATURE OF RELATIVE OR LEGAL REP. AND ADDRESS)
.Signed on this date:
i