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Grant, Margaret Ann rrorwiN0fF QQ18Q1R1Y PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director � 1 p Name MAR(4 / iy CRC id Case # 3Ck5 Date of Cremation 1 L — 9 61 Time Cremation Started l �� � a R ' v l Time Cremation Completed ! 7 V L-! ¶5 p ,AA Type of Container l OC-).5C-- B 1•Za'v C A5ret—w/A7C)--- z( op-al. Remarks : ,41 i N /3 I IR-R 44lU /1v 1 , � 5 0 II II � � 1 O PAA 1/ // ? ,- 1 ' 1J (mil .. . , ----e- 3? 3 v TOWN OF OUEENSBURY PINE VIEW CEMETERY • A CREMATORIUM Quaker Road, Queensbury, New York 12804 Phone (516) Crematorium 745-4477 or if no answer Cemetery 745-4476 • AUTHORIZATION TO CREMATE in The undersigneraqudeSts and gubjectautooitses Pine Rules view and Regulations' to accordance with cremate the remains oft Warne) (SeM) W.d /°� 2I- /'2*0((Strreeett ))e g (City) (State) (Zip Cod 6) (S of 19 who died on day 2, at (Place) (Address) Name and address of nearest living relative or name of , person authorizing cremations 17U a zgo / (Name) (Address) Relationship to the • deceased. ��''`` Name of Funeral Home -7n ' IMPORTANT: knowledge, the deceased has or I represent that to the best of my (Circle One) has no pacemaker in his or her body. I certify that I have the full power and authorization to arrang for the cremation of the remains and otol direct essthe iodispositionhof the cremated remains, that any pe rsonal posse e been removed or may be destroyed, and agree to protect, defend P e View um any and claims and eme harmless ssnor damagesewhichimayfbemmade againstlthen by and demands for orto dren whethernsuchd with claims ore cremation remains or are notwholly direccted,, groundless, f Ise or fraudulent. �� Gs��+ (7/2 ,44-glx VI . (Addres,sa ) t fitness) _ ---- (Signature of Relative or L gal Rep. and Address) Signed on this dates • 1 V AUTHORIZATION FOR CREMATION AND DISPOSITION r .,, 03I Rev.4/98 43TICF: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 Uwe have the full legal right and authority,and know of no living person who has a superior priority right under state law,to authorize the cremation,processing and disposition of the remains of Name afAeceagea 91- (hereinafter referred to as the"Deceased"). Date of Death Time of Death ❑ A.M. ❑P.M. I/We hereby request and authorize r. =. �-'- _. (hereinafter referred to as the "Funeral Home")to take ..y Name of hineral Nome possession of and make arrangements for the cremation of the remains of the Deceased at % Name of Crematory (hereinafter referred to as the"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: �,r Is special handling required? ❑Yes ego Describe Description of urn or container selected: Suitable for shipping: ❑ Yes ❑No ❑ Deliver to Cemetery Aoo Name ana tem of Cemetery ❑ Release to family Name of 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 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 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, 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 Disposition 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 anc irreversibly destroyed by prolonged exposure to intense heat and direct flame.I/We authorize the Crematory to epe e crematioi chamber during the cremation process and reposition the remains of the Deceased in order to facilitate a comp ete an riiugl cremation. 4. Certain items,including but not limited to body prostheses,dentures,dental bridgework,dental fillings2 jewelry,and other persona articles accompanying the remains of the Deceased,may be destroyed during the cremation process.UWe further authorize that i 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 pulverize 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 cr T of the Deceased in container which is not designated for any type of shipment. aF 8. In the event the urn or container is insufficient to accommodate all of the cremated remains i y excess cremate -reillealeitivelsbeii4acedln a secondary container and returned to the Funeral Howe,togeth Y,or container. 9. I/We understand and acknowledge,that even with the exercise of reasonable care and the 'Ybest ejforts,com not possible to recover all particles of the cremated remains of the Deceased,and that so y be commingled with particles of other cremated remains remaining in the cremation chamber ; utilized to proced the cremated remains. I/We hereby authorize the Crematory to dispose of any such resid ' y lawful manner deems appropriate. _ _ ... 41.:c. A..*i.n.•ivmtinn the e'rematinn.nrocessin2 and disposition of the remains of tt