Thompson, John s
rl-O`74N OF QUEEVB URY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director S/��1�,�,��/1�
Name_ /( e�2I� Case #�
Date of Cremation
Time Cremation Startediy`�
�
Time Cremation Completedl/415 rr ._� 4rNq
Type of Container cAlly&-i9go 021y'g'
Remarks :
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21 / /� r
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TOWN OF WEEN4HURY
pINE VIF-W CEMETERY
C"EMATURIUM
Qua)cer Road, pueensbury, New York 12804
phone (518) Crematorium 745-4477 or IF no answer
Cemetery 745-4476
AUTHURlznTIUN TU CREMATE
The undersigned)�ra,gdeSsub,jectautooits�,Rules View
and RegulationsCrematorium, to
accordance wit ,
cremate the remains oft
(Name)
(Sam)
(Street ) tCit 1 (State) ( Zip Code)
who died on day of
Ov
at �I e YES
(place) (A dress)
Name and address of nearest living relatiVit or name of ptr�ori
authorizing cremation(
(Name)
(Address)
Relationsl=ip to the deceased
Name of Funeral Nome
IMPURTEiNts knowledge, the deceased has or
res `it that to th best of my (Circle Une)
a pacemaker in his or her body.
to
ge
ion f
I certify that I have teereerainsll oand tower d direct rthe tdisposition na
for the cremation of the
any personal possessions have defend
the cremated remains, rotect,
been removed or may be destroyed, and agree to p
matorum
and save harmless Pir'e va siewewhichimayfbemmade against"y and lthen iby
and dem8tlds for lugs or dam damage
reason or or connected withe demrndscrem varevorsaare not awholly
directed, whether suc) claims or
groundless, false or fraudulent.
(Witness) (Address)
UUw
iature of Reive or Legal Rap. and Address)
t8igr � W
Signed on this dater
ti+ h
"Customer's Designation of Intentions"
k
Name of Deceased.:
Cremation: '�'ti •� l_ 1( t
(Scheduled Date) (Location)
Manner of Disposition of Cremated. Remains:
Burial at �#sReturn to Family
1, 1
❑ Entombment at ❑ Other (specify):
I herehy designate the Disposition of Cremated.Remains and acknowledge receipt of a copy of
this form.
w;
(S' ature) ,._ r
`..„...-..1-
(Printed Name) y (Relationship to Deceased)
(Address)
�4r� .,1
5 .t Ya
(Telephone Numher) y
"Cremated. Remains which shall not have been claimed. within 120 days front the 4te of
cremation may he disposed of by this firm by placement in a columharium."
Printed Name of Funeral Director Signature of Funeral Director Dat& =3
or Undertaker or Undertaker ns
TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF CREMATED.R MAIN ---4-- �
Cremation:
(Actual Date) (Location of Crematory)
Disposition of Cremated.Remains:
(Manner of Disposition)
(Location)
(Date)
Name of Person Making Disposition Signature Date
#9 WHITE:Funeral Home Copy YELLOW:Family Copy PINK:Crematory Copy CUSINTEN Rev.4/96
iiigned,
A O ZATION FOR CREMATION AND DISPOSITION
ICE THIS IS A LEGAL DOCUMENT. IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION.
MATION IS IRREVERSIBLE AND FINAL. READ THIS DOCUMENT CAREFULLY BEFORE SIGNING
certify,warrant and represent that I/we have the full legal right and authority to authorize the cremation,processing and
disposition of the rema;na oar- '� '_; `. , } > t� (hereinafter referred to as the"Deceased").
Name of Dec - ,_
Date of Death P( e— 'rune of Death "� "� ❑AM PM
I/We hereby request and authorize r -" i..rf !' (hereinafter referred to as the"Funeral Home")to
,) Name of Funeral Hoine
take possession of and make arrangements for the cremation of the remains of the Deceased at
(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 Funerale.IHoo
understand that the services and obligations of the Crematory shall he fulfilled when the cremated remains o the Deceased 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 KNo Describe
Description of urns or container selected: Suitable for shipping: ❑Yes ❑No
Deliver to �� 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.
�e cremationruing laare,Ithe rules�regulatig and��and policiessition of �of the Crematorye remains of e Deceased an Funeral Home,and the follherein ow be performed in accordance with all
d wing 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 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 noncumbustible materials, I/we authorize the remains of the Deceased to be
removed prior to cremation and placed in a combustible cremation container'. 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 mecha dioactive device. In the event the remains of the Deceased contain such a, device, I/we hereby
authorize the F neral Home, i agents and employees, to remove any such mechanical devices from the remains of the Deceased
prior to erema on, and diapose.e such items at its discretion. I/WE HEREBY CERTIFY THAT THE REMAIN$OF THE DECEASED
DO D NOT C ANY TYPE OF IMPLANTED MECHANICAL,OR RADIOACTIVE DEVICE.
Please ini' one.
L.ieted below are J,.Wplanted mechani4and radioactive devices which the Funeral Home is authorized to remove from the remains of the Deceased
prior to cremation,an of as indicated:
Description of Implanted Device Disposition
Description of)'mp Device �' +ePoeitio �-
If no instruction for disposition is given,such items may he disposed of at the discretion of the Funeral Home. 4
3. The cremation container containing the remains of the Deceased will be placed in the cremation chamber and will he toially"'knd
irreversibly destroyed by prolonged exposure to intense heat and direct fame. 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 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 he 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 pulverized to
an unideatifiahle 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 he placed in a secondary container and returned to the Funeral Home,together with the primary urn or containet
9. I/we understand and acknowledge,-that even with the exercise of reasonahle care and the use of the Crematory's hest efforts,it is not possible to
recover all particles of the cremated remains of the Deceased,and that some particles ma
'inadvertently become commingledwith Particles of
other cremated remains rpm ±nind in the cremation chamber and/or other devices u" d to process cremated
.1 . .1 n .-_- - 1•�_z_L___._.- - A-1 —,la",l manner it deems avorooriate.