Peck, Jane A OD
Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: u l," y,I 3
RETURN TIME: FlSnP
DATE 8 TIME REMAINS ARRIVED AT CREMATORY: S Z 73 2 :1
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERINGS�n
REMAINS:
_ P C 44115 (NC kU,e-
NAME: TA )E fEC cc — -
CASE # 3 g$
TYPE OF CONTAINER: A4Ei,ig-..r_we `G
w Lr11 '^)°w-,o 6D1rn
ivtU)
PLACE OF DEATH:
ESTIMATED WEIGHT OF REMAINS & CONTAINER
3s-0 /s 37s�4 ��
PLACED IN HOLD:
PLACED IN REFRIGERATION:
z:,o.
DATE OF CREMATION:
S 3 123
TIME STARTED: .1S'
'I TIME COMPLETED: iI'oo ,gn-L
PLACED IN RETORT: -7 ;c MOVED: /o.'C j
RETORT# IN WHICH REMAINS WERE CREMATED:
►� Di�v
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SHALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
M. • New York State
• Department of State
NEWYORK Division of DIVISION OF CEMETERIES
STATE OF ' One Commerce Plaza
OPPORTUNITY. Cemeteries 99 Washington Avenue
Albany,NY 12231-0001
Telephone:(518)474-6226
www.dos.ny.gov
Authorization for Cremation and Disposition
•
This Authorization Form must be completed and signed prior to delivery of remains for cremation.
Date: 5-1 I ' Case Number(for crematory use only):
Crematory Name: ?t'ne View C cemalDry
Address: 21 ( uc er 1?c •. ( LLee.ns bLA-ry N y 1 2troy Phone: S/I- 7 'S Y 2li
•
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation is carried out by placing the remains of the deceased and the container holding the remains into a cremation chamber where
they are subjected to intense heat and flame. The heat and flame will incinerate and consume everything except bone and metal,
which are all that will be left after cremation.
Following cremation,the crematory will take reasonable efforts to remove all of the remains and other material from the cremation
chamber,but some minimal dust and residue will likely be left behind. The crematory will separate incidental and foreign material from
the remains and the incidental and foreign material,including dental work and implants,will be disposed of as permitted by law. The
cremated remains will be mechanically pulverized into small pieces and placed into a designated container or urn. Cremated remains
generally are pulverized until no single fragment is recognizable as skeletal tissue.
OPENING OF THE CONTAINER
The crematory may only open the container holding the un-cremated human remains in limited circumstances,such as to confirm the
identity of the deceased or to ensure that no material is enclosed which might injure employees or damage the crematory property. If
human remains are delivered in a container which is not suitable for cremation such as ceremonial or rental casket,the
crematory will require that the remains be moved into a suitable container before it accepts the remains. The opening of a
container or the transfer or removal of remains will be conducted before a witness and will be done in privacy,with dignity and respect.
IDENTIFICATION OF DECEASED
•
Name of Deceased: J Ocfl.e i\ r�C1 Marital Status: --I);vo fet
Last Known Address: 32- 1 kU.e6 oa iefr• avurc• I 2.82g
Place of Death: b fenA PAS -i-Lcf•i-tA l/
Gender: ❑ M[�F ❑ X Age: (0 I DOB: giNI( 1/4 Date of Death: 1//4/20L3 Estimated Weight; 350
Description of casket/container' in which remains will be delivered,includingf manufacturer or supplier and material.
fi
T"� m_�TVRi (on"ctiner Cardboard w/ f/U6e.c1 60 i rn I,7):11WD(kP
PERSON IN CONTROL OF DISPOSITION
(P=;• ' control of disposition,initial ONE of the following)
lit% I am/We are the designated agent of the deceased designated in a will or written instrument executed pursuant to Public
-ea h Law Section 4201.
-OR-
I/We have no knowledge that the deceased executed a written instrument pursuant to Public Health Law Section 4201 or
a will containing directions for the disposition of his or her remains and I/we are the person(s)having priority under Public
Health Law Section 4201 and have the right to authorize cremation of the remains of the deceased. My/Our relationship
to the deceased is as follows: •
DOS-1898-f(Rev.01/23) Page 1 of 3
-Authorization for Cremation and Disposition
(Insert from the list below) •
Number: Description: V�/illi y�✓ 18' 1' s`Sk `'4 w'(1
•
A person designated in writing pursuant to Public Health Law Section 4201(3);
The surviving spouse; •
2a. The surviving domestic partner;
3. Any surviving child eighteen years of age or older;
4. A surviving parent;
0 A surviving sibling eighteen years of age or older;
6. A lawfully appointed guardian;
7. Any person(s)eighteen years of age or older entitled to share in the estate and who is/are closest in relationship to the deceased;
8. A duly appointed fiduciary of the estate; •
9. A close friend or relative who has executed a written statement pursuant to Public Health Law Section 4201(7);
10. A chief fiscal officer of a county or a public administrator appointed pursuant to the Surrogate's Court Procedure Act;
10a. Any other person who is acting on behalf of the deceased and who has executed a written statement pursuant to Public Health
• Law Section 4201(7).
For numbers 3,5 and 7 above,by signing,the person(s)signing this Authorization Form represent that they are signing on behalf of a
majority of the members of this class of persons who are reasonably available.
(Initi. BOTH of the following)
a 1 I e hereby affirm that the body of the deceased does not contain a battery, battery pack,power cell,radioactive implant,
it or radioactive device and that any such materials were removed prior to the execution of this Authorization Form. Failure
\ . to remove these items prior to cremation may result in
harm to the crematory and crematory personnel.
I/We affirm that instructions have been given to .J r Crv)\ r ni o n
(Funeral Director Name)
regarding the removal of any personal property or other thing of value which any person signing below or any family
member of the deceased wishes to preserve. T`n e v v t W £rc ' r/wvi
(Crematory Name)
is not responsible for the removal of personal items from the container or from the remains of the deceased. Personal
items left in the container or with the remains will be destroyed by the cremation process and cannot be retrieved
after cremation.
(Initial OPTIONAL) .
I/we hereby authorize the named funeral director to provide for delivery to and cremation by an alternate
crematory,if deemed necessary in the opinion of the funeral director,and to amend this form to provide the
correct name and address of such alternate crematory.
FINAL DISPOSITION V
The final resting place for the cremated remains of the deceased is
VZe+ n�d4D4 ;ly ,
If the funeral director whose signature appears on page three of this Authorization Form is not the person authorized to receive the
cremated remains of the deceased.from the crematory,provide contact information for that person or persons:
f ((4t J gait r?J� �I1 VJ�s V� `O`ldV'�/ ` ( Set /iv (Phone)
(Name) / (Address)
If for any reason the person named above does not take possession of the cremated remains,
'7ir)Qv +t, . CrerM•a�kor�, is authorized to give possession of
l (Crematoryame)
_ \
the remains tow
, (tiCk.Yr% J • �6A/it i cX)2) i-r by delivery in
t
(Funeral Home Name) •
in person or via delivery by the United States Postal Service,as permitted by its regulations and procedures.
Page 2 of 3
DOS-1898-f(Rev.01/23)
Authorization for Cremation and Disposition
(initial the following)
ikitI- e understand that if the remains are not claimed within 120 days of cremation,
-?inet etk/ Uerrtitbi may dispose of the remains in
(Name of Crematory)
an irretrievable manner;such as by scattering.
CREMATION CONTAINER/URN
(Initial ONE of the following)
I/We have provided 0)54.i with an urn to be used as a container for the cremated
(Name of Crematory)
remains.The urn is described as follows:
I/We understand that if the urn is too small to hold the entire cremated remains,an additional rigid container may be used
for delivery.
-OR
e have not provided an urn to be used as a container for the cremated remains,and understand that
i R e V i t W Cr C nudtai will place the cremated remains in
(Name of Crematory)
a rigid temporary container for delivery. ie.
,r I J 1 n�jv( (v /1 was executed at
This Authorization Form
`l
� was providedll / by ` (Funeral Director Name)
fj
(Fungi ome Name)
L02C l�. Proud y S i � i•475 N ��y &
(Funeral Plome Add )
and is signed by the funeral director as witness to its execution.
I/We have received a completed copy of this Authorization Form.
I/We is/are the person(s)in control of disposition,who by signing this Authorization Form,attests)to the accuracy and
completeness of the information contained in this Authorization Form and hereby authorize(s)to cremate the remains of the
deceased.
v►- ` 20 2 3
• Signed this r day of We-- t
Nlosy J O 1'1A C A 11s-4e r. )1(a jfit(A
Typed or Printed Name Si natu
Zoo e.Vc ( . EItvad /y /2
Address
Typed or Printed Name Signature
Address
Typed or Printed Name Signature
Address -
WITNESS: i!�
(Fune0(5)44-
ral r Typed o d Name) (Funeral Di r Signatu
1 vet
(Registration Number)
Page 3of3
DOS-1898-f(Rev.01/23)