Ryan, Michael OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director S 1�
NameNGH 12 El Py VAN Case#
Date Of Cremation
Time Cremation Started
Time Cremation Completed _
Type of Con tainer_ctq, j V2�'v—
Remarks
TOWN OF QUEENSBURY % ,1
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. in accordance with and subject
to its Rules and Regulations to crernate the remains of:
(NAME) (SEX)
(STREET) (CITY) (STATE) (ZIP CODE)
who died on day of 20,41
at &�
GZ " d 'Z/
(PLACE) ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
14
Relationship to deceased
Name of Funeral Home Y
IMPORTANT
I represent that to the best of my knowledge, the deceased has �ascemaker 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 gisposition 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 cl ims or dem ds are or are not wholly groundless, false or fraudulent.
(WI NESS) (ADDRESS)
0
(SIGNATURE OF REL/ATIVEOR LEGAL REP. AND ADDRESS)
Signed on this date: ` 5?/ ��
4. ; y I.IVAN�'ll [AlYPon=nndtAL mmm1 1
NY 12W
• tg�$3 T��i7
"Customer's Designation of Intentions"
� f
f Name of Deceased.
r Cremation:
(Scheduled Date) (Location)
Manner of Disposition of Cremated. Remains:
0 Burial at C., ❑ Return to Family
❑ Entombment at ❑ Other (specify :
I hereby designate the Disposition of Cremated.Remains and acknowledge receipt of a copy of
this form.
(Signature) r
(Printed Name (Relationship to Deceased)
(Address)
4 Ziff
Sf a
(Telephone Number)
I
"Cremated Remains which shall not have been claimed. within 120 clays from the date of
cremation may be disposed of by this firm by plac7el,-
ent in a columbarium."
"
Printed Name of Funeral Director Sid re of Funeral Director Date
or Undertaker 1 or Undertaker
TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF CREMATED REMAINS
Cremion:
(Actual Date) (Location of Crematory)
I
o ,emated Remains:
(Manner of Disposition)
I
I
(Location)
(Date)
I
AS ,
n
Name of Pe akin Disposition Signature Date
#E9 WHITE:Funeral Home'CoP7'�'! YELLOW:Family Copy PINK:Crematory Copy CLjSINTEN Rev.4/96
031 Rev.4/98
AUTHORIZATION FO R CREMATION AND DISPOSITIONING NATION.
I3IS IS A LEGAL DOCUMENT.IT CONTAINS IMPORTANT PROVISIONS CONCERN
_. 4;ti IS IRREVERSIBLE AND FINAL.READ THIS DOCUMENT CAREFULLY BEFORE SIGNING.
—�r m
e undtcined,certify,warrant and represent that Uwe have the full legal right and authority,and kn;e�
1. ing erson who has a super►or
tl► roeessin and disposition of the remains ofame-ler state law,o authorize the cremation,p g ? �7 - A M X EM.
priorlq r! to as the"Deceased"). 3 f 7�d 3 Time of Death
(herein Date of Death
(hereinafter referred t as the "Funeral Home")to take
p�st and authorize un
k. IJwe he' ame o era ome
of and make arrangements for the cremation of the remains of the Decease at
ame o rematory
posse', ion and custody of the Funeral Home.
-referred to as the"Crematory").
to the poss
1/We hereby authorize the Crematory li return the cremated
C Crematoryemains of the shall be fulfilledewhenthe cremated remains of the deceased are returned to he
I/We understand that the services and obligations of the Y
.UWe hereby authorize the Funeral Home to arrange for the disposition of the cremated remains o the
possession and custody of the Funeral Home
Deceased as follows:
Is special handling required`' - Yes No Describe
Suitable for shipping: Yes No
Description of urn or container selected: Cemetery
u Deliver to ame a ress o eme ery
Release to family ame o esignate amp y em r to ecerve remate mains
Scattering Scattering at sea by Funeral Home or Funeral Home's agent
Ship via U.S.Registered Mail*
Address
To:Name
Other
*Funeral Home and Crematory are not responsible for any loss or damage of cremated remains shipped via Registered Mail with the United fates
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
sid cremaion containbustible, leak
er.The Crematory is authorted for ized d to remove and di tion unless received by se of andles,ornament in a sland any other
resistant, p
noncombustible rip ble items attached to the cremation container prior to cremation. In t e event the remains of the Deceased are
received us 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 1
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 1
prior to cremation, and dispose of such items at its discretion. I/WE HEREBY CERTIFY THAT THE REMAINS OF THE
DECEASED DO - DO NOT kCONTAIN 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:
I
Description of Implanted Device Disposition
I
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 anq
irreversibly destroyed by prolonged exposure to intense heat and direct flpne.I/We authorize the Crematory to open the crematoot
chamber during the cremation process and reposition the remains of Deceased in order to facilitate a complete and thoroug�
cremation.
4. Certain items,including,but not limited to body prostheses,dentures4 dental bridgework,dental fillings,�'e�welry,and other person
articles accompanying the remains of the beceased,may be destroyed during the cremation process.UWe further authorize that i
any items other than the cremated remains of the Deceased, are recovered from the cremation chamber,they may be separates
from the cremated remains of the Deceased and disposed of by the Crematory. "v
5. I/We hereby authorize the Crematory to separate and remove from the cremation chamber all noncombustible materials,includin
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 pulveriz�
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 cremat�
remains will be placed in a secondary container and returned to the Funeral Home,together with the Drimary urn or cnntninPe.