Clark, James (70' 7+N OF QUEEVBU-r�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name C, 5 C �r � Case # ��
Date of Cremation Peed .�Qt 3� L 7005
Time Cremation Started ( . Wh
Time Cremation Completed
Type of Container s� ba �•� �� W-U S[�6N� 5
Remarks :
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Green Mountain Cremation Service
Middlebury, VT 05753
Phone:#802-388-2214 Fax:#802-388-1033
AUTHORITATION FOR REMATION AND DISPOSITI.o
NOTICE: THIS IS A LEGAL DOCUMENT. IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION. CREMATION IS THE
IRREVERSIBLE PROCESS OF REDUCING HUMAN REMAINS TO BONE FRAGMENTS THROUGH OPEN FLAME, EXTREME HEAT,
AND EVAPORATION. BEFORE SIGNING THIS LEGAL DOCUMENT, PLEASE READ, POLICIES, PROCEDURES, & REQUIREMENTS
ON REVERSE SIDE.YOU WILL BE ASKED TO SIGN THIS DOCUMENT.
I (We), the undersigned(the"Authorizing Agent(s)"), hereby authorization and request G.M.C.S., in accordance with and subject to its Policies,
Procedures and Guidelines,and any applicable state or local laws or regulations,to cremate the human remains and arrange for the final
disposition of the cremated remains,as set forth on this form:
Name of Deceased �� ��J ll: ,n L
I� Sex ��- J�_.--_- , Age '7o�
Place of Death S S- ��I y•
Date of Death 1a-
PACEMAKERS RADIOACTIVE IMPLANTS Did the decedent's remains contain a pacemaker,silicone implants,prosthetic devices,
radioactive implants,or any other explosive device Yes I.J No 1.1 If yes,please explain
PERSONAL POSSESSIONS List any personal possessions which will(check one) 1_I remain with the decedant for cremation or
will be f I removed prior cremation: describe:____
ERCHANDISE 1) Type of container the decedent's remains are to be placed in for transportation to and placement in the crematorium:
Alternative Container U Casket(type)
2) Type of container to hold the cremated remains in: U Urn
or Temporary Cardboard Container"
FINAL DISPOSITION Release cremated remains to the following Funeral Home, or Cemetery 1 1 Individual 1-i ,
Via Courier 11 or U. S.-P. S. O for shipment by Registered, Return Receipt mail, to:
Name cc
Relationship
Address -- I
City ----- State --------- Zip Code _—
SIGNATURE OF AUTHORIZING AGENT(S) / LIMITATION OF LIABILITY
As the Authorizing Agent(s),I(We)hereby agree to indemnify,defend,and hold harmless Green Mountain Cremation Service, its officers,agents and
employees,of and from any and all claims,demands,causes or causes of action,and suits of every kind,nature and description,in law or equity, including
any legal fees,costs and expenses of litigation,arising as a result of based upon or connected with this authorization, including the failure to properly '
identify the decedent or the human remains,the processing,shipping and final disposition of the decedent's cremated remains,the failure to take posses-
sion of or make proper arrangements for the final disposition of the cremated remains,claims brought by any other person(s)claiming the right to control
the disposition of the decedent or the cremated remains,or any other action performed by Green Mountain Cremation Service, its officers,agents,or
A1mployees,pursuant to this authorization,excepting only acts of willful negligence.
We),the ndersigned,hereby certify that 1 am the closest living next of kin of the decedent and that I am related to the decedent aEDlher ,
or that I otherwise serve(served)in the capacity of 1�
remains of the decedent and as such possess full legal authority and power to execute the aut or�ton from and to tothearrange for he, that I a and dive sposition
e of the
of the cremated remains of the decedent. THE UNDERSIGNED WARRANT THAT ALL REPRESENTATIONS AND STATEMENTS CONTAINED ON THIS FORM ARE
TRUE AND CORRECT,THAT THESE STATEMENTS WERE MADE TO INDUCE GREEN MOUNTAIN CREMATION SERVICE TO CREMATE THE HUMAN REMAINS
OF THE DECEDENT AND THAT THE UNDERSIGNED HAVE READ AND UNDERSTAND THE PROVISIONS CONTAINED E THIS FORM AND THE ACCOMPANY-
ING POLICIES,PROCEDURES AND REQUIREMENTS STATED ON REVERSE SIDE.
Licensed Funera r(Si n re)• G j
1 Signature- t-f✓�- .rlk',�t ��
- - -- Name ----- -- ----- --- �
Name and Address of Funeral Homer --�� - ------
Address
n r I city
- tic-�� �'�3 State 7�Z�— zip
Witness(Signature): s3
Date Signed 'I
CREMATORY USE ONLY
Auth. I I Permits: M.E.❑ Burial ❑ Date of Cremation
Cremation No. i.
Time: Started Completed Container