Ringrose, Thomas Title ViC-w Cemetery & CI'( 111i1to1-IuIlI
Quaker Road
Queeimbury, NY 12804
(518) 745-4477 or (,518) M5A,476
Re'(wesl.ed Re(urn 'f'inle
Naulc------- �.�.�---- ^ -S� ------ -- -.....--- -Case No. �Q
Date of Cremalloll-__ ����---`l�lnle stilrtccl_ �V,
--�___._
Placed in 1-1olcl:
Placed In in Refrigcratiorl:
Placed in Retort:
Type of Conf,lincr .------- Igtn _--
Remarks
Main Z° Al
------------------- Movc
- fi-
Place of Dca(11---- -� -- ---1c)p��
Estimated Weigle.of Remains and Coll u1incr_-- %SO Ij�J3
Date K Tin1c Remains arrived al.Crematory_ _-
Name of Funeral Director or Rcgistcral Resident Delivering Remains____
Dctajled reason Io,- delay if remains were cre►uawd 11101-e (flan 148 hours from tulle of accepted
delivery
------------------------------
Reto1•t Nwullcr in which Remains were crcnlalal� -------------------------------------
Note:'1'hc Cre nlaliot� 1,og shall he rctainccl in the Pcrinancnt 1'ilc of the Crematory
I
New York State
NEWYORK (�IVIs10R Of Department of state
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 Aut or zedon Form must be completed and signed prior to delivery of remains for cremation.
I 111 Number. &I S
Crematory Name:Pine View Crematory
Address: Z QvrKt, err 1.g Phone: (Sit) I'l i-I I I)
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 Hell take reasonable efforts to remove all of the remains and other material from the cremation
chamber,but some minimal dust and residue will)lke)y be left behind. The crematory will separate incidental and foreign material from
the remains and the incidental and foreign material will be disposed of as required by law 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 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 XCCEASED D
Name of Deceased:_/ e i11,4.5 E. /, i,u 9 r-e s Marital Status:
Last Known Address: }o a)fe, 4U� S cif r��U AA N Y• ��1 y
Place of Death: E 1d e r-iA c A 0 mA °t e-* 16-L S K 114 12 S A)m4Xi /J x
Sex: 6 ❑F Age: _DOB: Q / Date of Death r2 qllFlcXC I Estimated Weight
Description of casket/container in which remains will be delivered. ! /
PERSON IN CONTROL OF DISPOSITION
Person(s)in control of dispodtbri,)nitial ONE of the following)
!am/We are the designated agent of the deceased designated in a will or written instrument executed pursuant to Public
Health Law Section 4201.
-0R
I/We have no knowledge that the deceased executed a written instrument pursuant to Public Health Law Secton 4201 or a
Will containing directions for the disposition of his or her remains and Uwe are the persons)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:
end
DOS-1898-f(Rev.08/15) Page 1 of 3
AuthodmHon for Cremation and Disposition
(Insert fham the ristbelow)
Numbed Description: _ � ) Cj r V 1 W�i (ten l
1. A peen designated in writing pursuant to Public Health Law Section 4201(3);
2a. The spouse:
Then►win9 domestic paitrw.
3. Any surviving child elgl teen years of age or older:
4. A surviving parent:
S. A surviving sibling eighteen years of age or older,
6. A 6iwfully appointed guardian;
7. Any person(s)eighteen years of age or older entitled to share in the estate and who islare closest in relationship to the deceased;
S. A duly appointed fiduciary of the estate;
9. A dose friend or relative who has executed a written statement pursuant to Public Health Law Section 4201(7);
10. A chief fiscal oftiaer of a county or a piblic admirristratrx appolrrtad pcusjmt jD the SurroggWs Court Procedure a Act:
10a. Any other perm who is acting on behalf of the deceased and who has executed a written statement pursuant to Public Health
Law section 4201 M.
(Inlf&t ALL THREE of fhe following) -
hereby affirm that the body of the deceased not contain a battery,battery pack,power radioactive implant,
th
or radioactive device and at any such materials were removed prlo' execution of this AuthorbWon Font. Failure to remove
these Items prior to cremation may result In harm to the crematory and crematory personnel.
UWe affirm that intrust ms have bowl glVen to 6 ,s. !C
regarclirg the removal of any personal property or other thing of value which any person signing below or any fancily member of the
deceased wishes to preserve. Pine View Crematory
is not responsible for the removal of lemon aaa�
personal items from the corrtairmer 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.
(22�9 hw9by authorize Pine View Crematory
(G--WYftOW
to cremate the retrains of the dthcease.
FINAL DISPOSrtION
The person authorized to receive the cremated remains of the deceased from the crematory is:
Name.Any Staff from the Edward L Kelly Funeral Home
Address.1019 US RL 9 PO Box 548.Sc hroon Lake,NY 12970 Pion:518.532 7177
The cremated remains of deceased will be disposed-of as follows:-
�e�i-,)4 'Fe E'g4ot-7 / 1041-cs-�--
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
the remains to Edward L Kelly Funeral Home by delivery
in person or by registered mail.
D05-18Wf(Rev.08115) Page 2 of 3
Authorization for Cremation and Disposition
ln-el the following)
I/We understand that if the remains are not claimed within 120 days of cremation,
Pine View Crematory may dispose of the remains in
Oftm of )
an irretrievable manner,such as by scattering.
CREMATION CONTAINMWRN
(ln"al ONE of the following)
An um to be used as a container for the cremated remains has been purchased from Edward L Kelly Funeral Home
and is described as follows
I/We understand that if the um is too small to hold the entire cremated remains,an additional rigid container may be used for delivery.
-OR
An rs not yet pu as a and that if no tun is purchased or otherwise provided_
1`lE1r will place the cremated remains in
a rigid temporary container for delivery.
i
This Authorihadon Form was provided by D�N was executed at
(Funeral Q'ret�rNarm)
Edward L Kelly Funeral Home
1019 US Rt.9,PO Box 548 Schroon Lake,NY 12870
(Funeral Hm-Add-=)
and is signed by the funeral director as witness to its execution.
I/We have received a completed copy of this Authorization Form.
The person(s)identified below islare the person(s)In control of disposition,who by signing this Authorfzatlon Form,attest(s)
to the accuracy and completene of the information contained in this Authorization Form and authorizes)the foregoing.
Signed this FA day of
Typ�forPrhued Name
-F e- 0 e-eA) hid LY / s—O
Typed nrPruded Now SOW—
Address
Typed or POW Name g
Ad%=
WITNESS:
(Fimerdfah?d rTyxdorPrin(edName) 7owb5
ww
11�g
( arraWn NumDerJ _ --
► N f os� Sr
(N—ai'DecibseM
003-1898-f(Rev.08/15) Page 3 of 3