Villa, Carol Pill(- View Cerllet:e;ry & Crelrla(.01"utn
Quaker Road
Quce wbury, NY 12804
(5)18) 711,5-4477 or 0)18) 745-4476
Recluestecl Rel.urn '(`iule
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Name ar� �S
--------_ -- _ _CaSC No.
Date o!'Crcnl,uion___—�I811�---'1;,11e Starlcrl �'s� "l'inlc Conll>Icrccl. 3 /G
Placed in Hold: ------------
Placed ill Refrigerat1011:
Placed in Rctoru Z_OC>Pt�__
Type of CollGunet
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Remarks
Main
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Place of Death-------tttf--=P—D—' --6 C— Etj_.Frt L --------------
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Estimal.ed Weight.of Remains and Conlilinel. (fib
Date V tine Remains arrived al.CretllatorY_ `I I 1 /,�� -
Name. of Funeral Director or Reb„tared Resident Deliverilig Retn�l►ns_ nu n ie
Detailed reason Io,- delay if renlauls VVCl'C C"elllal.ed more (Ilan 11.8 hours from tilue of accepted
delivery
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Retort Number in which Remains were cl'ctllatcd SuPE�
Note:'Hie Cretuation Lot;shall he retained in the PCt'ttlallCnt Pilc of the Crematory
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ONew York SlGt=
tt pp Department of State
NEW YORK DIVIsiOR Of DIVISION OF CEMETERIES j
STATE OF One[omrrerce PUZa
O ► OPPORTUNITY 94 Washington Amenve
C Cemeteries Albany.NY 12 2 31-0 0 01
d Teiephonw(sla147"128 i
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Authorization for Cremation and Disposition
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This Auttrodiall Form must be...plated and signed prlar to delivery of r/a�malns for orentatlon.
Date —1 I I, I I� Number.
C Ciematory Name.Pine View Crematory
N
Address Quaker Road,4ueensbury,NY 12804 Phone,518-745.4477
C 'CREMATION 13 AN IRREVERSIBLE AND FINAL PROCESS.
N Cremation is tarried out by placing the remains of the deceased and the container holding the remains into a cremation chamber where
10 i they are subjected to intense neat and flame. The.ltest and flame win Indriamte and consume everything except bone and metal,'
Z which are all that will be left after cremation-
0 Following cremation,the crematory will take reasonable efforts to remove all of the remains and other material from the cremation
C cnamber,but Some minimal dust and residue will likely be jell behind. The crematory will soparale incidental and foreign material from
the remains and the incidental and foreign material will bea disposed of as required bylaw. The cremated remains will be mechanically
pulverized into small pieces and placed into a designated container or um. 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 Me crematory property. If
human remains are delivered In a container which is not suitable for cremation such as eeremoniai or rental casket,the
crematory will require that the remains be moved Into s 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
Card L.Villa yt�tlKetl
Name of Deceased: Marital Status.
The Pines,Warren Rd.,Glens Falls,NY 12801
Last Known Address:
F18Ce0fDeath. �) `�� IL1 5NN I —
_
Sex: 0 M ®F Age: I A 51411929 DOS: Date of Death. —I b ,(_q Estimated Weigh: 170__
Description of caskelloontafner in which remains will be ivered.
Basic Cremation Container
PERSON IN CONTROL OF OISPOSITION
(Peraron(s)in control of dispostion, le;1 ONE of the!allowing)
-- 1 am We are the designated agent of the deceased designated in.a will or written instrunwnt executed pia suant to Public
JH" ,v Section 4201.UWa havenoknowledge that the deceased executed a written instrument pursuant to Public Health Law Section 4201 or a ?
ring "act ails for the disposition of his or her remains and I/we are the person(s)having priority under Public Health Law ry.
Section 4201 and have the right to authorize cremation of the remains of the deceased MyiOur relationship to the deceased Is as ?,
follows:
Carol L.Mile t
r
LL DOS-1898-f(Rev.08/15) Page 1 of 3
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Authorization for.Cire;;i6on and Dispols(tion i
N
O (insert from the fist bakxv) s
O 3 son
d Number Desc6pbon: __ ---
f` 1. A person designated in writing pursuant to Pubic Health Law Section 4201(3);
2 The surviving spouse, j
2a. The surviving domestic psrtner,
3. Any surviving child eighteen years of age or older,
4. A surviving parent;
5. A surviving gibing eighteen years of age or older,
6. A lawfully appointed guardian;
C 7. Any person(s)eighteen years of age or older entitled 10 share In the estate end who Were closest in relationship to the deceased:
7: 8. A duly appointed fiduciary of the estate; i
O 9. A does friend or relative who has executed a written stat9ment purcuant to Pubic Health Law Section 4201(7); I
N 10. A chief fiscal otfioer of a county or a public administrator appointed pursuant to this Surrogate's Court Procedure Ad,
O7 10a. Any other person who is aping on behalf of the dooeased and who has executed a written statement pursuant to Public Heath
Law,Section 4201(7).
O (t 'lal L THREE of fhe lolbwug)
N
kWe hereby affirm that the body of the deceased does not contain a battery.battery per,poilver cell,radioactive httplant,
1n or radioactive device and that any such materials were removed prier to the execution of this Authorization Form. Failure to remove
O
these i me prior to cremation may result in harm to the crematory and crematory personnel.
f
-1rWe afrm that instructions have been given to Patricia Miller
' r raraeam 1 r
regarding the removal of any personal property or other thing of value which any person signing below or any family member of the
Pine View Crematory
deceased wishes to preserve. _—
ror++twr
Is no responsible for the removal of personal items from the container or from theremains of the deceased. Personal items left in the
contain or with the remains will be destroyed by the cremation process and cannot be retrleved after cremation.
IIWe hereby authorize
View Crematory
rCewro,9y NenNl
t
to cremate the remains of the deceased,
FINAL DISPOSITION
The person autlhorized to receive the cremated remains of the deceased from the crematory is:
Nam:Brewer Funeral Home,Inc.representitive
Add-ass:_24 Church St.,LakeLuzerne, Phone:NY 12846 518-696.2744
_ _ j
The cremated remains of deceased will be disposed of as follows:
burial in St Marys Cemetery,South Glens Falls
If for any reason the person named above does not take possession of the cremated remains,
Pine view Crematory is authorized to give possession of
. raeebka AYur) 'I
the remains to Brewer Funeral Home,Inc. by delivery
!F'Maa'rnm.rW.ray �;
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vim person or by registered mail.
Cara L.Vita r
{Nd,Ltl PreOLOelY6pi Y ' .'.
C DUS-1898-f(Rev.08/15) Page 2 of 3
c Authorization for,Crematlon•and Disposition
� c
O ► ( i the foAowmg) {
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d w blue understand that If the remains are not claimed within 120 days of cremation,
Pine View Crematory
r may dispose of the remains in
r frwne a cnrtwrorn
V an irretrievable manner,such as by scattering. j
C ION CONTAINERfURN
(W ONE of thefo&wiing)
LO An um to be used as a container for the cremated remains has been purchased from
Brewer Funeral Home,Inc.
Hudson Blue Urn
Q and Is described as follows:
N IMo understand that if the urn is too Small to hold the entire cremated remains,an additional rigid container may be used for delivery.
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IN
An urn is not yet purchased. INVe understand that 4 no um is purchased or otherwise provided
Pi
s'�emst v,`..;:�-:'t, Z„ ;,a� ;u�y Siv+.r 4ul�y� . •f» y�'w_;,�r Latl w,. ,:•F '
will place(ha cremated remains In
Vi
Iv+m.eroom.km
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a rigid temporary container for delivery.
This AuthortzaUon Form was provided by Patricia Miller was executed at
lrv�aav Weernremti
Brewer Funeral Home,Inc.
24 Church St.,Lake Luzern,NY 12846.
and is signed by the funeral director as witness to its execution. ,
;/We have received a completed copy of this Autiiorindon Form. ;
Tho person(s)identified below Ware the person(s)in control of dlapoalflon,who by signing ails Adtnor&sUon Form,attest(s)
to the accuracy and completeness of the Information contained in this Authorization form and suthorize(s)(he foregoing.
Signed this day of zo'
Peter Villa
lrpao YPanpOAlims
55 H ghview Circle,Brockport,NY 14420
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WITNESS:
Paincia Miller _
==.rm/lflY['(p•76rda
12465
i1Tn�rerron ,
Carol L.Villa p:
s
(Mu„e oreoeasay F .
0.OOS-189&f(Rev.08/15) Page 3 of 3 „'