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Tucker, Dorothy OF QUEENSBU,'Ky PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director_ �� h `2Te �f�l 1I,- 1 Z Case; 11r� 'date Uf Cremation =17e Cremation Started T =Te Cremation Completed . , ^e of Container Kemarks — U Z . TOWN 01= OUEENS©URY PINE VIEW CEME1•EhY 2� � r CREMATORIUM Quaker Road, Queensbury. New York 12804 Phone (510) Crematorium 745-4477 (if no answer) Cemetery 745-447G ` • AUITIORIZA'f"ION '1 O GREMAI E The undersigned requests and aulhuiizes Dine View laemalmuni, in accurdance with and subject to its Rules and Regulations to cremate the remains uf: (NAME) (SEX) bb c` SIC C�-o (STREET) (CI"fY) (STATE) (ZIP ODE who died on _�4' day of at FIACE) (A DRESS) Name and address of nearest living relative or name of person authorizing cremation: Relationship to deceased CC Name of Funeral Home IMPORTANT 1 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. (WITNESS) _ (ADDRESS) (SIGNATURE Or RELATIVE OR LEGAL REP. AND ADDRESS) SIg1ltZtf Oil this date: v PG`I wow AUTHORIZATION FOR CREMATION AND 40 DISPOSITION �� 031Rev.4/98 U::THIS IS A LEGAL DOCUMENT.IT CONTAINS IMPORTANT PROVISIONS CON CERN IING CREMATION. CREMATION IS IRREVERSIBLE AND FINAL.READ THIS OCUMEIYT CAREFULLY BEFORE SIGNING. I(We,the undersigned,certify,warrant and represent that Uwe have the full le priority right under state law,to authorize the cremation,processing and disposition of the rema right and inst fan�i know of no living person who has a superior (hereinafter referred to as the"Deceased Date of Death Z) Time of Death I/We hereby request and authorize '� t����:w s'. �, A.M. ❑ EM. n ame o „nevi Dine v _ (hereinafter referred to as the "Funeral Home")to take possession of and make arrangements for the cremation of the remains of the Deceased at [ (hereinafter referred to as the"Crematory"). 'r r Q \;�� Name o 'rematory 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 cZn� ! Suitable for shipping: C Yes ❑No '\\ ❑ Release to family Ram o eme ry Cemetery Name ❑ Scattering at sea by Funeral Home or Funeral Home's agent° remat mains ❑ Ship via U.S.Registered Mail* To:Name Address ❑ Other *Fueral Home a nd Crematory are not responsible for any loss n 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 cremation chamber. The Crematory will not cremate any human remains which contain an t e 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 an yy such mechanical devices from the remains of the Deceased prior to cremation, and dispose of such items at its discretion. I/WE HEREBY CERTIFY THAT THE REMAINS OF THE DECEASED DO ❑ DO NOT'-❑ CONTAIN 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: Description of Implanted Device tion Disposi. 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 open 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,i,��'e�welry,and other personal articles accompanying the remains of the eceased,may be 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. 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