Gohn, George 70WN OF Q7 \[Y8T1R
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director` TO/V — ��
Name d ja (� 7)//X Case #
Date of Cremation /
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Time Cremation Started / r /0
Time Cremation Completed t2:CO Pi/` )
Type of Container C1 �1lk/9X J ,5ig /
Remarks :
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TOWN OF UUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, in
accordance with and subject to its Rules and Regulations to
cremate the remains of:
6eb e 1--N/ YALF
(Name) `Sex)
7 )--k,2-/,54Ve 26, 1 0(, . QS6 0-8y
(Street) (City) (State) (Zip Code)
l,` �� 44FE.X 19
who died on (���-(�-fir' �� day of
at 1`1.hl D`-/�s '✓FA 6Ei
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation: V QQ M n �!
L PrISOV2
(Name) (Address)
Relationship to the deceased a-HZ
Name of Funeral Home
i � AE/4LY
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or
has V 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.
(Wi s ) (Address)
(Signature of Relative or Legal Rep. and Address)
Signed on this date: ./,? /� // 1
at • -
Ai i t
( -1 1 ci) 73- 4
"Customer's Designation of Intentions"
r
Name of Deceased: ;
-
Cremation: ---:37:1(11, LI • . /
(Scheduled Date) (Location)
Manner of Disposition of Cremated Remains:
El Burial at r-c-
Return to Family
0 Entombment at 0 Other (specify):
I hereby designate the Disposition of Cremated Remains and acknowledge receipt of a copy of
this form.
•
(Signature)
AVVI. OfriV
(Printed Name) (Relationship to Deceased)
67? - (. C,Vir ‘)
(Address)
- 1 cc
t (
._
(Telephone Number)
"Cremated Remains which shall not have been claimed within 120 days from the date of
cremation may be disposed of by this firm by placement in a columbarium.”
.•
• ,
or
Printed Name of Funeral Director Signature of Funeral Director ate
or Undertaker or Undertaker
TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF CREMATED REMAINS
Cremation:
(Actual Date) (Location of Crematory)
Disposition of Cremated Remains:
(Manner of Disposition)
(Location)
(Date)
Name of Person Making Disposition Signature Date
WHITE:Funeral Home Copy YELLOW:Family Copy PINK:Crematory Copy CUSINTEN Rev.4/96
41
ATTACH AUTHORIZATION FOR CREMATION ANC DISPOSITION
BOOKLET
HERE NOTICE THIS'IS A1'EGAL 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 I/we have the full legal right and authority to authorize the cremation,processing and
disposition of the remains o (hereinafter referred to as the"Deceased").
Name of Deceased ,
Date of Death j-,/'9f` Time of Death L/ ��0se A.M. ❑P.M.
I/We hereby request and authorize rG L r / (hereinafter referred to as the"Funeral Home")to
Name of Funeral Home
tolce possssion of and make arrangements for the cremation of the remains of the Deceased at ,� ;/`� ar L u) rIL.7`"
(hereinafter referred to as the"Crematory"). Name of Crematory
I/We authorize the Crematory to return the cremated remains of the Deceased to the possession and custod of the Funeral Home. I/we
un
rstand
t the
ions
he Crematory
to
thedph and ys and of the Funeral Home.e. I/We hereby shall befulfilledFunhen the era Home cremated
otarrange for the dispositionof th are e t cremated
possessioncustodyy authorize the
remains of the Deceased as follows:
Is special handling required? ❑Yes ❑ No Describe
Description of urn or container selected: Suitable for shipping: ❑Yes ❑No
r Deliver to 4-J c Cemetery
Name and Address 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
rocessing and disposition of
t
remains of
hall
governing laws,/the rules,regulations and policies lof the Crematory yand Funedral Home,aanded yrein the following be performed
and conditions:accordance with all
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 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, jewelry, and other
personal articles accompanying the remains of the Deceased, may be destroyed during the cremation process. I/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.
horize the
5. I/Wl hereby
touthinges,latches,nails,jewelr to y and precarate drOus mve etals�and to dispose of sm the cremation uch matmber erials.
6. materials, including, but
not6. 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 designed 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.
9. I/we understand and acknowledge,that even with the exercise of reasonable care and the use of the Crematory's best efforts,it is not possible to
recover all particles of the cremated remains of the Deceased, and that some particles may inadvertently become commingled with particles of
other cremated remains remaining in the cremation chamber and/or other devices utilized to procss the cremated remains. I/We hereby
authorize the Crematory to dispose of any such residual narticls in,any lawful manner it deems aunronriate.