Denike, Baby Girl J
7f"wN OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director 164E4k- Q��-�(
NameAggy 2,� !&E Case # Z46
Date of Cremation
Time Cremation Started_ tZ I
Time Cremation Completed o2',3�
Type of Container G/9J��Gd/9/r'� ,3j�,a, � �0� lW1-G�
Remarks : ��_
TOWN OF QUEENSBURY
PINE VIEW CEMETERY& CREMATORIUM --
Quaker Road, Queensbury, New York, 12804 /
Phone(518) Crematorium 745-4477 of 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:
(Na ) (Sex) f
Ap� k�-z
(Street) (City (State) (zip)
who died on day of 20
at 0-4- �L�SQ �
(Place) (Address)
Name and address of nearest relative or name of person Authorizing cremation:
\D C-n)'\c9--
(Name) (Address)
Relationship to the deceased
Name of Funeral Home
IMPORTANT:
1 represent that to the best of my knowledge, the deceased has r�sndacemaker 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.
(Witness) (Address)
( ignature of Relativ-e or Legal Rep. and Address))
Signed on this date:
oOKLE AUTHORIZATION FOR CREMATION AND DISPOSITION
HERE NOS 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 ' ned ce � .
fir$ r rtiy,warragt and represent that I/we have full legal right and authority to authorize the cremation,processing and
disposition of the remains of rA t. .�.
_1 Name of Dec. (hereinafter referred to as the"Deceased').
;- Date of Death "0 Tune of Death
❑A.M. El P.M.
I/We hereby request and authorize .,t , ...iq s` , "'z _- } \4 (hereinafter referred to as the"Funeral Home")to
Name Fume Ho e 1 l ,
take possession of and make arrangements VI
C
for the cremation of the remains of the Deceased at .S.J
(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 custody of the Funeral Home. I/we
understand that the services and obligations of the Crematory shall be fulfilled when the cremated MCI
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:
Is special handling required? ❑Yes f No Describe
Description of um or container selected: Suitable for sbipping: Yes ❑No
Deliver to
Cemetery
Release to family "R .�`, s, tr 1 ,i '� az" and Adds yf�c ete�
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 he 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"noncomhustible 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 noncombus&ble materials, I/we authorize the remains of the Deceased to be
removed prior to cremation and placed in a combustible cremation contains 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 Funer ou�its agents and employees, to remove any such mechanical devices from the remains of the Deceased
prior to cremation,;and li sp ..o
DO 0 DO NOT f such items at its discretion. I/WE HEREBY CERTIFY THAT THE REMAINS OF THE DECEASED
CONTAIN ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE.
Please initial one. j', ,_ (Cr
Listed below are all implanted mechaf cal and radioactive device.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 Dsvice 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
rrrever -W destroyed by prolonged exposure to intense heat and direct fume. 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 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 crfmation chamber, they•f;:..T:
may he rsee�paarated from the cremated remains of the Deceased and disposed of by the Crematory.
5. �ebhuted tou�g a lla ches,nnaadi s,j w tory to lq and p arate a us metals,nd to dispose of uremove from the cremation l ch at rials mber A noncombustible materials, including,but
not 6. Following cremation, the cremated remains of the Deceased, consisting primarily of hone fragments, will be mechanically pulverized to
n unidentifiahle consistency prior to placement in an urn or other container.
7. Unless an um 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 um 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 urreor 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 n inadvertently become commingled with particles of
other cremated remains remaining in the cremation chamber and/or other devices utilized to process the cremated remains. I/We hereby