Johnston, Henry 70�v OFQUEEVBU9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director 2e�Ltv Ll
Name I-I�N ►z vt�NAlS`�6T1 Case# a
Date Of Cremation
Time Cremation Started
Time Cremation Completed
Type of Container T) �� d1,•,
Remarks
1 r 1 �ti�S ,�n v✓E F7 3 5' ��`�
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TOWN OF QUEENSBURY i t O
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:
Hen,-u ►'Y> J r
(Name) (Sex)
(Street) (City) (State) (zip)
who died on day of 'J 20 U3
at
(Place) (Address)
Name and address of nearest relative or name of person Authorizing cremation:
(Name) (Address)
Relationship to the deceased 'a 3,
Name of Funeral Home -
IMPORTANT:
I represent that to the best of my knowledge, the deceased has r�snoacemaker 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, Gnu 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)
� � v
ignature of R41ative or Legal Rep. and Address))
Signed on this date: ��
AUTHORIZATION FOR CREMATION SAND DISPOSITION I cia)IRev.4/98
NO, 7_ICE:THIS IS A LEGAL DOCUMENT.IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION.
CREMATION IS IRREVERSIBLE AND FINAL.READ THIS DOCUMENT GAREFULLY 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
(hereinafter referred to as the`Deceased").
fVame o ecease
Date of Death 03 Time of Death
UWe hereby request and authorize � A.M. ' P.M.
e » a.V (hereinafter referred to as the "Funeral Home")to take
possession of and make arrangements for the cremation of the remains of 7be Deceased at
(hereinafter referred to as the"Crematory"). — P% V;a
ameo cren—my
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:
_! Deliver to
Suitable for shipping: Z1 Yes i i No
ame an ress o eme ery 17 Release to family Cemetery
— ame o ignat amp y em r[o ecewe remate emams
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,etca m ard
_ cre hazate any human remains whh ain-any type of
when placed in the cremation chamber. The Crematory will not crem
implanted mechanical or radioactive device. In the event the remains of the Deceased contain.,such is I/we hereby
authorize the Funeral Home,its agents and employees,to remove any such mechanical devices from tb ins She Deceased
prior to cremation, and dispose ,, uch items at its discretion. I/WE HEREBY CERTIFY THAT. REMAINS OF THE
DECEASED DO DO NOTACONTAIN ANY TYPE OF IMPLANTED MECHANICAL OR" IOACITIVE DEVICE.
Please initial one.
Listed below are all implanted mechanical and radioactive devices which the Funeral Home is a `rized10 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 t e nera ome.
3. The cremation container containing the remains of the Deceased will be placed in the crematiolFi chamber and will be totally aid
irreversibly destroyed by prolonged exposure to intense heat and direct flame.I/We authorize th4Crematory to open the cremation _,
chamber during the cremation process and reposition the remains of the Deceased in order to facilitate a complete and thorough bw
cremation.
4. Certain items,including,but not limited to,body prostheses,dentures,dental bridgework,dental fil 'ewet and-other personal
articles accompanying the remains of the Deceased,may be destroyed during the cremation process. a further authorize'that if
any items,other than the cremated remains of the Deceased, are recovered from the cremation cha er,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 noncombible mat s,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 , ani erized
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 o e ed 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;aiiy exee�s emated
remains will be placed in a secondary container and returned to the Funeral Home,together with the primary urn or container.