Fuller, Janet PrNE Y(EFY CEMETERY
��•� ROAD, ND CREMATORIUM
QIlEE.NSBURY' IYEW PORK 128pq
(518) 745.4476 (518) 745'•4.477
Funeral
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AUTHORIZATION FOR CREMATION AND DISPOSITION
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 legal right and authority, an know of no living person who has a superio
priority right understate law,to authorize the cremation,processing and disposition of the remains of TZCZL-L—L:.
(herein after referred to as the"Deceased").- Name of Deceased
Date of Death A22i L' i 1 12-001 Time of Death
[ )A.M. [ J P.M.
I/We hereby request and authorize 4.&) * t Z6 (hereina er refer=toase"Funeral Home")to take
NameofFuneralH sllpossession of and make arrangements for the cremation of the remains of the Deceased at r h t (W �D t'tUitit
(hereinafter referred to as the"Crematory"). Name of Crematory
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? [ j Yes [ ]No Describe
Description of urn or container selected: Suitabl¢for shipping: [ ]Yes [ j No
[ j Deliver to
Noma and Address of Cemetery Cemetery
[ ]Release to family
Name or Designated Family Member to Receive Cremated Remains
[ ]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 in 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,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. IMe 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 rerp`ainss of the Deceased prior to cremation,and
dispose of such hems at Its discretion. VINE HEREBY CERTIFY THAT THE REMAINS OF THE DECEASED DO[ ] DO NOT IXI 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 aulhori;rid!o remove from thoxQw.is-0f OwDaceased prior to cremation and dispose
----- --ofas indicated:
Deecrlplbn of Implanted Devka
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 or direct flame. IMe 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 fillings,jewelry,and other personal articles accompanying the remains of the Deceased,may be
destroyed during the cremation process. IMe 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. IMe 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 um or other container.
7. Unless an um or container suitable for shipment Is purchased,the Crematory will place the 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 um or container.
9. IMe understand and acknowledge,that even with the exercise of reasonable care and the use of the Crematory's best efforts,If is not possible to recover all particles of the
cremated remains of the Deceased,and that some particles may inadverlently become commingled with particles of other cremated remains remaining in the cremation chamber
and/or other devices utilized to process the cremated remains.
10. Unless I/we give specific written Instructions in this Authorization,the cremation,processing and disposition of the remains of the Deceased will not be performed in accordance with
any particular religious or ethnic customs.
11. In the event the cremated remains of the Deceased remain unclaimed for a period of 30 days,the Funeral Home shall give written notice to me/us by certified mail at the address
listed below, flute agree that in the event the cremated remains of the Deceased remain unclaimed,for a period of 120 days after such written notification is mailed,the Funeral