Funk, Marilyn OF QUEEVBUr�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
`;ame_
Case„
Date Of Cremation
T =me Cremation Started •, �,�
lime Cremation Completed
'ape of Container�j4� `�3e� u� �UaC:J _
Remarks
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TOWN 01= QUEENSDUR Y ,?
PINE VIEW CEMETERY ;
CREMATORIUM
Quaker Road. Queensbury, New York 12804
Phone t518) Crematorium 745-4477 (if no answer)
Cemetery 745-4476
AUTHORIZATION "10 CREMAI E
The undersigned requests and authorizes Dine View Crematurium. in accuidance with and subject
to its Rules and Regulations to cremate the remains ul:
(NAME) (SEX)
(STREET) (CITY) (STATE) (ZIP CODE)
- who died on _ ( day of c-�f r" Zo D-3
at — C)_6-V\ ,"�W.
(PLACE) (AD RESS)
Name and address of nearest living relative or name of person authorizing cremation:
VI r t , / Kat/\�c�
Relationship to deceased
e
Name of Funeral Home k �'
IMPORTANT
I represent that to the best of my knowledge, the deceased has Iias no p ernaker 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.
4((WITNESS) RESS
SIGNATURE OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date:
��,�e`� AUTHORIZATION FOR CRYIATION AND DISPOSITION 031Rev.4/98
SCE:THIS IS A LEGAL DOCUMENT.IT CONTAINS RTANT 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 knowof no living person who hal a superior
priority right understate law,to authorize the cremation,processing and disposition of the remains of / � J `mod- �. - . / !,
(hereinafter referred to as the"Deceased'). Name or Eveceased
Date of Death r Time of Death ❑ A.M. A P.M.
I/We hereby request and authorize I i ,,+ .° 'i �� - -( (hereinafter inferred to as the "Funeral Home")to take
ame""nem nume
possession of and make arrangements for the cremation of the remains of the Damaged J
(hereinafter referred to as the"Crematory'l. Name of MiMW
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 V No Describe
Description of urn or container selected: Suitable for shipping: ❑ Yes ❑No
❑ Deliver to Cemetery
sine
Release to family� t C 1- t r t r , ;
�..fD.,P.WFwiwMembutoRmiveCmmakdRemaMs
❑ 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 Deceantauthoriaed.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 cremat4on'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,
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 aCinitine.
device. In the event the remains of the Deceased contain such a device I/we hereby
authorize the Funeral' e nd employees,to remove an�ysuch mechanical devices from the remains ot�the Deceased
prior-to cremation, andf s items at its discretion. 1JWE HEREBY CERTIFY THAT THE REMAINS OF THE
DECEASED DO ❑ ❑CO TAIN ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE.
Please
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:
Description of Implanted Device Dlspositi-
Description of Implanted Device Disposltio4.
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 open thecremation
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,jewelry,and other personal
articles accompanying the remains of the beceased,may be destroyed during the cremation process.I/We further authorize that if
any items,other than the 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. 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.
.. — . . —-'-- "--a .——- __.___..._._O ____--A ar......__r H... h—& U-
C'"rirUMN-MA FEU I,HOW � ?
407 ftfoad
Quwasbury.NY 12544
(518)M 4459
"Customer's Designation of Intentions"
Name of Deceased: �. i" 1. .. '`
Cremation: `y
(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.
t ' 4(Signature) f
(Printed Name) (Relationship to Deceased)
a"
(Address)
(Telephone Number)
"Cremated. Remains which shall not have been claimed. within 120 clays from the date of
cremation may he disposed of by this firm by placement in a columbarium."
t �r '? �:.-� '�', (r i t 1 ; }�-•T f��t.�..,tom,,./�y� / � ....
Printed Namt of Funeral Director Siodulat4tre of Funeral Director Date
or Undertaker or Undertaker
TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF CREMATED REMAINS
Cremation:
(Actual Date) (Location of Crematory)
Disposition of Cremated Remains:
(Manner of Disposition)
(Location) 1;
(Date)
Name of Person Malang Disposition Signature Date
#9 WHTI'E:Funeral Home Copy YELLOW Family Copy PINK:Crematory Copy CUSINTt N RevA/96