Bray, Ruth rO q4N OF QUEEVBU9�Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director 1511rf0q
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Name ROTH I M ,�( 16 "11-1 Case# 3 (,
Date Of Cremation :� - (-? - '7 ci::5; ?�
Time Cremation Started
Time Cremation Complete^^dam�
Type of Container �(�}\�fl �Qt�I�FJ �Uw�t
Remarks
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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 Crematorium. iri accordance with and subject
to its Rules and Re ulations to cremate the remains of:
�. A
(NAME) (SEX)
G '4LI� 6 U
(STREET) (CITY) (STATE (ZIP CODE)
who died on day of �c' ' 20 03
at &xn 1i �L CD Ill
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
CCX-f 0 GAA, DSO �DCJ(V4 GEC(. 0-
Relationship to deceased
Name of Funeral Home S fy-\ - * asA�
IMPORTANT
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. j
(WIT ESS) (ADDRESS)
(SIGNATURE OF RELATIV R EGAL REP. AND ADDRESS)
Signed on this date: C
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(�ii®O�Iri v NY 12804 �
"Customer's Designation of Intentions"
F.
Name of Deceased.:
� i
Cremation: ._f F _ V ::h
(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
tins form. R
1
(Sig+na e)
r"�
r A:C.; 1 . ..'
(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 by placement in a columbarium."
Printed Name 4 Funeral Director Signatur`e�of Funeral Director + Date
or Undertaker or Undertaker
TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF CREMATED REMAINS
I
Cremation:
(Actual Date) (Location of Crematory)
Disposition of Cremated. Remains:
(Manner of Disposition)
(Location)
(Date)
Name of Person Making Disposition Signature Date
#9 WHITE:Funeral Home Copy YELLOW:Family Copy PINK:Crematory Copy CUSINTEN Rev.4/96
o�4w 031Rev.4ry8
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 I/we have the full legal right and authority,and ow of,no living person w has a superior
priority right under state law,to authorize the cremation,processing and disposition of the remains of Name o ease
(hereinafter referred to as the"Deceased"). Date of Death 7 Q3 Time of Death . SO � A.M. P.M.
L l�I/We hereby request and authorize 1�T� (hereinafter referred to as the "Funeral Home")to take
ame o unera ome ,.^n 1 f
possession of and make arrangements for the remation of the remain of the Deceased at • i� v ame o remalory
(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 No Describe
Description of urn or container selected:,' �" 1 Suitable for shipping: Yes No
Deliver to . mean o eme ery Cemetery
—
*Release to family P-�
ame of plrg.atdamp em r to Receive ureimite emains
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 crematio hamber. The Crematory will not cremate any human remains which contain any type of
implanted mechanical or device. In the event the remains of the Deceased contain such a device I/we hereby
authorize the Funeral Ho ,its 't d employees,to remove any such mechanical devices from the remains of the Deceased
prior to cremation, and spose of s terns at its discretion. I/WE HEREBY CERTIFY THAT THE REMAINS OF THE
DECEASED DO NOT C N AIN ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE.
Pleas in ial on .
Listed below are all im Ila e I anN
oactive devices which the Funeral Home is authorized to remove from the
remains of the Deceased pri ion,apose 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 opel}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.I e further authorize that if
r - any- f,4"er thaiiAhe-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. dIn the event the urn or container is insufficient to accommodate all of the cremated remains of the Deceased,a6y excess cremated
remains will be placed in a secondary container and returned to the Funeral Home,together with the primary urn or container.
a i/Wa...,aareto...l —1 anlsnncxr.A— tha+—on math tha avarrica of raacnnahla Tara andl the ucp of the VrPmatnrv'c hpct Pffnrtc it is