Walker, Alma rrn7+N OF" QUEEVBUJ�Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director. A05grAly eL
Name-&019 41�� Case #
Date of Cremation /c-"j -'
r
Time Cremation Started / J /� /d,-M r
e
Time Cremation Completed o2 t AY61 1,!21
Type of Container / jyr
Remarks :
1'OI)N O I.10I_1=NSIAMY
PINE VIEW CEME'1'E1(Y
CHEIIIATUI?I Utll
Quaker Road, Uueensbury, IVew Yuri( 1E004
Phone (510) Crematorium 745-447.7 or i1= no answer
Cemetery 7It5-4476
AUTHOR I VIT I ON TO CREMATE
The undersigned requests and authurizes Pine View Crematorium, in
accurdance with and subject to its Rules and Regulations to
cremates tl-ie remaains uf .
A�rrn GAL LAJcd kr Fryno 11 __-•
(IJanry) (Se,c )
for4 " }IudIn., 1'U0r_)inU F
(5t•rvvt ) (C4 ty) (State) ( Zip Code)
who died on 2 7fh day of, lUp;iPn,be- 2000
• a t �y�� /"7)1 rl yy� /Uts rS i.tea /�nm c
(Place) (Addr, ess )
Name and address of nearest living relative or name of per-sun
authorizing cremation : n
(Name) (Addre s s )
Relationship to the deceased —�rzvv,lAc.- _
Name of Funeral Home,- cr,.o.,-,
IMPORTANT:
I that to the best- of my I(nowledge, the deceased) has or
has no pacvmalter in his or liar 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 r\e;mains, 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 crenlat,Jan of said remains as
directed, whether such claims or demands are or are not wholly
groundless, fa or fraudulent .
( tness ) (Address )
lor,
(Signature of Re ative r Legai Rep. and Address)
VT
Signed on this date : �l
4.
ftAl-
"Customer's Designation of Intentions"
Name of Deceased.:
Cremation:
(Scheduled Date) (Location)
Manner of Disposition of Cremated.Remains:
❑ Burial at to Family
❑ Entombment at ❑ Other (specify :
I hereby designate the Disposition of Cremated Remains and acknowledge receipt of a copy of
this form.
1
l
(Signature)
(Printed Name) (Relationship to Deceased)
(Address)
(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 Signature of Funeral Director Date
or Undertaker or Undertaker
TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF CREMATED REMAINS
a
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
FROM : 24t�ilRR1;;TONS OF HORSESHOE 0:iY �+ n t r c PHONE NO. B30 59S 6515
}, � X69459 We:RAF C.RAPHfC9 NC: •01P)951-457E •• -
AUTHORIZATION FOR CREMATION AND DISPOSITION
N 7 :THIS IS A Lk C,Af,DOCUMENT.iT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION.
CREIIIATION 1S IRREVERSIBLE AND FINAL.READ THIS DW(JMENT CAREFULLY BEFORE SIGNING.
Me,the undereignW,certify,warrant and represent that Uwe have the hill legal right and authority,and know or no living person who has a superior
prlorily right under state law,to authorize the cremation,processing and disposition of the remains of� ) �
(hereinafter reNeti-ed to as the."Decrand'I. eme -----
Date of Death_j1 Z2 7106 Thne of Death C A.M. C? P.Nt
UAVe hereby regoestand authorize t'{�y,u„ it x
,�aC c A 4 vn (hereinafter referred to as the "Funeral Home")to take
possessiun of and make arrangements for the cremation of the remains of the Deceased at�%r7 t- U i e
(hereinafter referred to as the"Crematory"), —
IrWe hereby authorize the Crematory to return the cremated remains of the deceased to the possession and custody of the Funeral Wine.
I/We understand that the services and obligations of the Crematory shall be fultilled when the cremated remains of the deceased are returned to the
possession and custody of the Funeral Home.LWe hereby authoriA the funeral Home to arrange for the disposition of the cremated retnalas of the
Deceased as follows:
L special handling required? [l Yes>4 No Describe -—_-
Description of urn or container selected Suitable for shipping: 0 Yes r. No
n Deliver to
-- ------��a Cemetery
J Release to family__
♦mt a IWAil"i" em?u K --
rl Scattering at sea by Funeral Home or Funeral Route's agent
lJ Ship via U.S.Registered Mali*
To:Name Address
D Other
" Mn—vral Home and Crematory are not responsible for any s or damaige orcrtmattil remains shipped via Registered KGO with the United Sfated
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 rufeR,regulations and policies of the Crentatery,and Funeral Home,and the following terms and conditions;
I. 'rhe remains or the Deceased will not he accepted for crellention unless received by the Crematory in a combustible,leak
resistant,rigid cremation container.The Crematory is authorixed to remove and dispose of handles,ornaments and any other
noncombustible items attached to the cremation container prior to cremation, In the event the rentains of the Deceased are
rectived b} the Crematory in a casket or other Container constructed of meteil,fiberglass,or other noncombustible materials,
Ilwe authorize the remains of the Deceased to be removed prior to cremation and placed iu a combustible cre►nation container.
I;We further authorize the Funeral Horne or Crematory to make disposition of any such noncombustible casket in any lawful
manner it deems appropriate.
Z. 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 Uwe hereby
authorize the Funeral Home,its agents and employees,to remove any such mechanical devices from the remains ohhe Deceased
prior to cremation,and dispoSevorf.such items at its discretion, 13VE HEREBY CERTIFY THAT.THEREMA NS OE THE
D1 CEASED DO L.' DO NOONTAIN ANYTYPE 0 F IMPLANTED MECHANICAL OR,RADIOAC'1'IVE DEVICE.
Please initial one.
Llited 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:
D. yti".rtmpawl.daerka D titw
_.__..__....C:CirlilbaW,y.tie1t6rn1tN►•frra•wnoar-....re,w..........,�,.�--_...... .. _..... •..... ........... .. ... ..................__......... ... •... ... ,..,...._......
SIGNATURE OF PERSONS)AUTHOPUZING CREMATION AND DISPOSITIONT
IIS'Ve warrant that all representations and statements made herein are true and correct, and that I/vre have read and understand the
provisions contameAln this document,And that I/we have received the booklet entitled"Cremation Facts".
SignatoIle
r.atic�tc �� t• em.
Address Rat -,, , '� ` , 7a�. 7U^.Y�--_ t Tel.No.(S* ) L&P Z780
.yp. ]SiLl��y
tatull
runt Raw -7t*,s 7 satrhlp to L><tt.18ed r`
AddreC9�C'1`71 �i.�t-n C CY;ism}yyxle1.No,('
gt•eet city hue V
Date: Y