McCoy, Myron OF QUEE9 5BU-r�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURy NEW YORK 12804
(518) 745-4-476 (518) 745-4477
Funeral Director, 5 ,��-l. i'-k�'►.� � �ya�til
aMeCI'r �Dx/ C
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�a t o 01 Cremation _ 2S
!me Cremation Started
T 'Te Cremation Completed 1
VP e of Container Cep,\z-C) 30,4cxfL�
Remarks
J "10 A ^�
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TOWN 01: OUL=ENSDURY
PINE VIEW CEMETERY I�J�
&
CREMATORIUM
Quaker Road. Queensbury. New York 12804
Phone t5l0) Crematorium 745-4477 (it no answer)
Cemetery 745-4470
AUTI-IORIZAT-ION '10 CREMA-1 E
The undersigned requests and authorizes Dine View Lrenratomm. in accurdance with and subject
to it Rules and Regu Pt
ons to cremate the remains of:A
404 C
ccitti
E) % (SEX)
,2 e 2W
(STREET) ( I i (STA-1-11) (ZIP CODE)
who died on �r�l day of ����` - 2u 45
at a l?'Y �Is T7r, -
(PLACE) r (ADDRESS)
Naqed address f n rest living relati or name of per yr uthorizing cremation:
l� � z It N
Relationship to deceased AV� '
Name of Funeral Home �71 f1 r if Ile r14 LJIMA-17'
IMPORTANT
I 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 reason of or connected with the cremation of said remains as directed, whether
s c i s ema ds are or are not wholly groundle false or frau ulent.
U 61� ' u 12�6
(WITNESS) (ADDRE )
(SIGNATURE OF RELATIVE/OR LEGAL REP. AND ADDRESS)
Signed on this date: • �� ��
G`�'S
;wi AUTHORIZATION FOR CREMATION AND DISPOSITION 031 Rev.4/98
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 Vwe have the full le 4 of ne Gving person who has a superior
pnontyrVit, irider'sW law,to autho ' OV&remains of
(hereinafter da- - � r ame di mmawd
/ J
r' Date of Death- �'�/?GCS Time of Death f �J ❑ A.M. &.M.
r
V� u r> ' + vc_i LL' 'Y �(� referred as the "Funeral Home")to take
I/We hereby request and authorize (hereinafter t9
ame ome -
possession of and make arrangements for the cremation of the remains the Deceased at �i 'd V(f't �.r`` t y t
(hereinafter referred to as the"Crematory"). ame rematory
I/We hereby authorize the Crematory to return the cremated remains of the deceased to the possession and custody of the uneral 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 1 (No Describe
Description of urn or container selected//: Suitable for shipping: ❑ Yes ❑No
.: Cemetery
ame ana AuM o em ry
p.Release to family
Name of Dedgnatedam em ve Cremated Reinains
❑ 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
ce�yed-,by the Crematory in a casket or other contabtervonstructed of metal,fiberglass,or other noncombustible materials,
9 re
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, aRnd dispose of such items at its discretion. IfWE HEREBY CERTIFY THAT THE REMAINS OF THE
DECEASED DO Q DO NOTCONTAIN 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:
D1W0l - -
MK paon or Implanted nevi« sna
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 too en the cremation
chamber'luring the gemation 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 fillin gs,�e-welry,and other personal
articles accompanying the remains of the tieceased,maybe destroyed during the cremation process.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. Foloowing cremationi the-cremated remaiVafflf the_Deceased,consisting primarily of bone fragments,will be mechanically pulverized
to an unidentifiable consistency prior to places-n W Ad urn or other contain.
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 Trove,mAo +and and a.-knaw1PdiaP_that even with the exercise of reasonabRe care and the use of the Crematory's best efforts,it is i