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Curley, John 2-0W C OF QUEEN45BURY PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director 5, Name /y Case # /'j—� Date of Cremation — a000 Time Cremation Started �1 Lr d r T Time Cremation Completed 16Q Ft AA Type of Container ��j �,�p�n1J /57G�jo/�' Remarks : / /9 Al) 11o2; TOWN OF UUEEN5HURY pINE VIEW CEMETERY ' cfiEMATUR I UM Quaker Road+ Queensbury, New York 12804 phone (518) Crematorium 745-4477 or of no answer Cemetery 745-4476 AUTHUn I ZAT ION TU CREMATE The undersigned requests and authorize! Pine View Crematorium, in accordance with and subject to its Rules and Regulations to cremate the remains oft (Name) ' (City) 9 _(State) ( Zip Code) (Street ) 1 d 2—M who died on day ofQ / at ►� (Place (Address) Name and address of nearest liVing relatiVO or name of , person authorizing crem tiont - 1 (Name) (Address) Relationship to the Cde�ceased Name of Funeral Nome 1U In IMPURTANT2 knowledge the deciraised has or I represent that to the best of my g + /This no-�►aeemaker in his or her body. (Circle (]ne) I Have the full power and authorization to arrange I certify that to for the cremation of the remains ersonaldipossessionsshaveteither the cremated remains, that any P to rotect defend been removed or may be destroyed, and agree p + and save harmless be any ma anainstlthemi s Pine View Crematorium f •�y �'--.,,. and demands for loss or damages which may g reason of or connected lamwith e o ll o said s or demrndsareorare not+Wholly directed, whether such claims groundless# false or fraudulent. Nitness) (Address ) c� (Sign tur of Relati a or Legal Rep. and. Address) Signed on this datet W ATTACH AUTHORIZATION FOR CREMATION AND DISPOSITION BOOKLET HERE NOTICE THIS IS A LEGAL DOCUMENT. IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION. CREMATION IS IRREVERSIBLE AND FINAL. READ THIS DOCUMENT CAREFULL-f BEWARE SIGNING VWe,the undersigned, r t and represent that I/we have the full legal right and authority to authorize the cremation,processing and (hereinafter referred to as the"Deceased disposition of the remains o a i.`.. t ' ' 1: -tit ' Name Deceased Date of Death ) 1 I�'Ki <p`'1 Time of Death ❑AM. ❑PM. I/We hereby request and authoriz< ,\A V(�n- 1 "'d', 1- hereinafter referred to as the"Funeral Home")to Funs Home Name o f take possession of and make arrangements for the cremation of the remains of the Deceased at � k.tlA (hereinafter referred to as the"Crematory"). Name of Crematory I/We authorize the Crematory to return the cremated remaions of the ns of the Deceased to the possession and custody of the Funeral Home. I ed when the rem the pounderstand e ssioonn and custody of the Funeralt the services and Home. i/We hereby authorizz shall be e tthhe Funeral Homeo ar ngge for th}ehdisppositie Deceased of the cremated remains of the Deceased as follows: Is special handling required? ❑Yes L No Describe Description of um container selected: \ Suitable for shipping: Yes El No Deliver to _T I i" C J f1W 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 cremation, rocessing and disposition of the remains of the Deceased authorized herein shall be performed in accordance with all —" governing laws,de 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 ny lawful mannr 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- dioactive device. In the event the remains of the Deceased contain such a device, I/we hereby authorize the Funeral Home, agents and employees, to remove any such mechanical devices from the remains of the Deceased prior to cremation and dispose�uch items at its discretion. M HEREBY CERTIFY THAT THE REMAINS OP THE DECEASED DO 0 DOXOT /' _ C ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE. Please initial on F Listed below are all implaiitwd-mec cal and radioactive devices wluch the Funeral Home is authorized to remove from the remains of the Deceased prior to cremation,and dispose o as indicated: Description of Implanted Device Disposition Mnlplented`Devtoe _r �•�. r... ., _._..�� �::;. ......... .. ,I�iepeeikiptl..-- ,zav+�+�+w.. .ee.scwau..- :.. ....,.,.,. _. If no instruction for disposition is given,such items may he disposed of at the discretion of the Funeral Home. I 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 orderto facilitate a complete and thorough cremation. 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 he 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 of the Deceased and disposed of by the Crematory. may he separated from the cremated remains 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 pulverized to an unidentifiable consistency prior to placement in an urn or other containeL 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 he 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 beet efforts,it is not possible to recover all particles of the cremated remains of the Deceased.,and that some particles ma inadvertently become commingled with particles of . other cremated remains *prrL�*+�� in the cremation chamber and/or other devices utilized to process the cremated remains. I/We hereby