Kimmey, Henry l O Y V N OF QUEE9\ 5BWKY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director -
Name 6'4! YAy y lrl� t Case # Aft
Date of Cremation /a,-1(" oZdC1j
r
Time Cremation Started f r—
Time Cremation Completed f) '03 M
Type of Container JC7rq.D x ,-G � 4,
Remarks : —
TOWN OF WEEN"URY
pINE VIEN CEMETERY
CREMATORIUM
uuaker Roadt uueensburyr New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
nUT14UR1tnTION TO CREMATE
The undersi94ithrequests
sub�edtautooitsdsRples View
and RegulationsCrematorium,
to
in
accordance
cremate the remains oft
(SON)
t am
(City) (State) ( ip Code)
tStre t >
who died on day of 7 - U
at (plac- tgddress)
e)
Name and address of nearest liVing relatiV# or naae of Pfrlur'
authori z ir.g cramat i on t
(Name) (Address)
Relationship to the deceased
Name of Funeral Nome
1MMITANta Ftnowled a the decreased HSI or
1,_ seat that to the best of my (Circle l7ne)
has no aGa!saker in his or her body. `
I certif
the full power and authorization to arrange
y that I have
the cr-erRation of the remains and to dirossessionsshava either
for ersonal p
the creaa'=ed remains, that any p protect, defend '
been removed or may be destroyed, and agree to
e save oved or Pine View Crematorium from any and
lthemibY
arid which may be made against
and demarids for loss or damages
reason of or conrleCted with claims ore cram
aendsoareoorsaare notawholly
directed whether such
groundless false or fraudulent.
fitness ) (Address)
71 al Fie and. Address) '
(gignaturp of elative or eg p•
Signed on this dater
��. y,✓ `'! � �_.�� A ��`` f Mom.. �►
"Customer's Designation of Intentions"
Name of Deceased.:
Cremation:
(Scheduled Date) (Location)
Manner of Disposition of Cremated.Remains:
❑ Burial at )i?Return to Family
❑ Entombment at '❑ Other (specify):
I hereby designate the Disposition of Cremated.Remains and acknowledge receipt of a copy of
this fo
f
(Signature)
(Printed Name) Telationshi to Deceased)
(A"Xess)
(Telephone Number)
"Cremated. Remains which shall not have been claimed. within 120 clays from the date of
cremation may be disposed of by this firm by placement in a columbarium."
Printed Name of Funeral Director SignatfpfFuneral Director D to
or Undertaker ndertaker '
TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF CREMATED REMAINS
is
4;
Cremation:
(Actual Date) (Location of Crematory) {
Disposition of Cremated. Remains:
(Manner of Disposition)
i
(Location)
(Date)
Name of Person Making Disposition Signature Date
#9 WHITE:Funeral Home Copy YELLOW:Family Copy PINK:Crematory Copy CUSINTEN Rev.4/96
ATTACH AURWRIZAT'ION FOR CREMATION AND DI p
BOOKLET SPOSITION
HERE NOS THIS IS A LEGAL DOCUMENT.
I/We,the undersigned,ce IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION.
CREMATION IS IRREVERSIBLE AND FINAL. READ THIS DOCUMENT CAREFULLY BEFORE SIGNING
nt y, t and repreyent that I/we have the full legal right and authority to authorize the
disposition of the remains of r `�q' ,.}t ;t j f r tT' (hereinaftercremation,processing and
Name o referred to as the"Deceased").
Date Qf Death I r Tine of Dea I/We hereby request th
and authorize i «s .�, — •,- ,. A.M. El P.M.
` _ L (hereinafter referred to as the"Funs Home")to
take possession of and make arrangementsior the cremation of the remains of the Deceased at //ZQ_ �V!J';,LAJ
(hereinafter referred to as the"Crematory")•
I/We authorize the Cremato r the Name Crematory
y to return a 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 }theDeceased the possession and custody of the Funeral Home. I/We hereby authorize the Funeral Home to arrange for the dispositi nn of the rec cremated
remains of the Deceased as follows:
Is special handling required? ❑Yea )(No Describe
Description of urn or container selected: Suitae for shipping: ,
❑ Deliver to bl h PPing: ❑Yes ❑No
Release to - Name and Address of Cem►tet�v
Cemetery
Name of mgnated Family ember 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.
Ile
ercremation ing lawn,the r processing
reguland
dos and policiesposition tthe the remain,
Cre of the
an Deceased
authorized herein shall b rf d '
e pe orme m accordance with all
-
governing d Funeral Home,and the following terms and conditions:
I' The remains of the Deceased will not he accepted for cremation unless received by the Crematory in a combustible, leak resistant, 40 cremation container: The Crematory is authorized to remove and dispose of handles, ornaments and any other noncombustible i
attached to the cremation container prior to cremation. In the event the remains of the Deceased are received by the Crematory in a
or other container constructed of metal fibs y rglass, or other noncombustible materials I/we authorize the remains of the Deceased to ��:"
removed prior to cremation and placed in a combustible cremation container. I/We further authorize the Funeral Home or Crematory'
matte disposition of any such noncombustible casket in any lawful manner it deems appropriate.
2. Mechanical or radioactive devices im lanted in the remains of the Deceased h
p (such as pacemakers, etc.) may create a
when placed in the cremation chamber. The Crematory will not cremate any human remains which contain any type:;.
implanted mechanical or radioactive device. In the event the remains of the Deceased contain such a device, I/we he
authorize the Funeral Home; 'ts agents and employees, to remove any such mechanical devices from the remains of the Dec
prior to cremation, and dispos�''of such items at its discretion. LVE HEREBY CERTIFY THAT THE REMAINS OF THE DEC
DO (_] DO NOT ONTAIN ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE.
Please initial one. ' }
Listed below are all implanmiiecitical and radioactive devices which.the Funeral Home is authorized to remove from time remains of the /y
prior to cremation,and dispose;A as indicated:
De"ptipn.of ImA-ted 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 total�y
irreversibly destroyed by prolonged exposure to intense heat and direct flame. I/We authorize the Crematory to open the cremation
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 o •._
personal articles accompanyin the remains of the Deceased, may he destroyed during the cremation process. I/We fu
authorize that if any items, other than the cremated remains of the Deceased, are recovered from the cremation chamber, .
may be separated from the cremated remains of the Deceased and disposed of by the Crematory.
6. I/We hereby authorize the Crematory to separate and remove from the cremation chamber all noncombustible materials, including,
not limited to,hinges,latches,nails,jewelry and precious metals,and to dispose of such materials. R
6. Following cremation, the cremated remains of the Deceased, consisting primarily of hone fragments, will be mechanically pulverized F
an unidentifiable consistencynor to placement in an urn or prior p other contains,
7. Unless an urn or container suitable for shipment is purchased, the Crematory will place the cremated remains of the Deceased rrx
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 he placed in a secondary container and returned to the Funeral Home,together with.the primary urn or contain,, -
- -9. I/we-understan&-anal aAnowledge,that even with the exercise of reasonable care and the use of the Crematory's best effDrts,it is not possible to
recover all
other cremated e8emains the
s remammg n the coremationn chamber and/or other devices ma
'z'eld vroces the become
crema remains. IWeherebv