Ames, Joan r �
fine View Ccnicl.cry & Crcmatoriunl
Quaker Road
Que:cnsbury, NY 1280/1,
(.518) 7/1-5-4/1-77 or 018) 711-5-4/1-76
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delivery
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Air fr'orization for Cremation and Disposition � n tenState
One Commerce Plaza.99 Washington Avenue
Albany,NY 12231
(518)4 T4-6226
www.dos.state.ny us
ONES
This Audwrization form must be compieted and skned prior to delivery of remains for cremation.
Date:1/2/2019
Crematory Name:Pine View Crematory --
Address:Quaker Road, Queensbury, NY 12804 Phone:518-745-4477
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation is carried out by platting 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 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 CONTAINER
The crematory may orgy 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 crematory Property. If human remains are delivered in a container which is not suitable for cremation
such as a 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.
IAENTIFICATION OF_DEGEASED
Name of Deceased:Joan M.Ames Marital Status:Married
Last Known Address:114 Lake Abanakee Rd., Indian Lake, NY 12842 j
--
Eiderwood at North Creek, 112 Ski Bowl Rd., North Creek, NY 12853
Place of Death: _ -- -
Sex: ❑M OF Age:87 D0B:9130/1931 Date of Death:1/1/2019 Estimated Weight:100#
Description of casket/container in which remains will be delivered:
PN .basiccardboardcremationcontainer
PERSON IN CONTROL OF DISPOSITION j
(Person(s)in control of disposition, iroai ONE of the following)
I am/We are the designated agent of the deceased designated in a will or written instrument executed
pursuant to Public Health Law section 4201.
I
-OR-
s� I/We have no knowledge that the deceased executed a written instrument pursuant to Public Health Law
1 or a will containing directions for the disposition of his or her remains and (Continued next page) j
.loan M.Ames
DOS-189844 (Rev.01/10)
Name nl t]rrrAwsAd'—Y----------------~--PaOe 1 0(3
+L I ainf 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:
(Insert from the fist below)
Number-a Description-SOW -ra --
1. A person designated in writing pursuant to Public Health Law section 4201(3);
(Phe surviving spouse;
2a.The surviving domestic partner;
3.Any surviving child eighteen years of age or older;
4.A surviving parent;
5.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 isiare closest in
relationship to the deceased;
S.A duty appointed fiduciary of the estate;
9.A dose friend or relative who has executed a written statement pursuant to Public Health Law§4201(7);
10.A chief fish 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§4201(7).
(ini W ALL THREE of the following)
�,I/We hereby affirm that the body of the deceased does not contain a battery, battery pack, power cell,
radioactive implant,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.
,,, UWe hereby affirm that instructions have been given to (A,,,* MichaelMiller
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. (c,emsio„y na,m)Pine View Crematory is not
responsible for 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.
Uwe hereby authorize(aematon,narne)Pine View Crematory to cremate the
remains of the deceased.
FINAL QI$POSITION
The person authorized to receive the cremated remains of the deceased from the crematory is:
Name:Miller Funeral Home
Address:6357 State Rte. 30, Indian Lake, NY 12842 Phone:518-648-0011
The cremated remains of deceased will be disposed of as follows:
Retumtofamily
If for any reason the person named above does not take possession of the cremated remains,
(cnvnw +y nww)Pine View Crematory is authorized to give possession of the remains to
Ifunerm h„8, )Mier Funeral Home _ by delivery in person or by registered mail,
Joan M.Ames
DOS-18M44 (Rev.01/10) Namn o1(?8ffa.W 1 Page 2 of 3
r
V
(inifiel the following)
t I/We understand that if the remains are not claimed within 120 days of cremation,
(CM-W&y„0.)Pine View Crematory may dispose of the remains in an irretrievable manner.
such as by scattering.
C EMAnON CONTAM f R RR
(Initial ONE of the fbHoMng)
An um to be used as a container for the cremated remains has been purchased from
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-
ko An um has not yet been purchased. I/We understand that if no um is purchased or otherwise provided
rcre.o y ) Pine View Crematory will place the cremated remains in a rigid temporary
container for delivery.
This Authorization Form was provided by(rawet orectm name) MichaelMiller
was executed at&.»ra►rar►m,.ns?Miller Funeral Home
tfunerar twrr►e addlnsss) 6357 State Rte. 30, Inaian Lake, NY 12842 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
Authorization Form,attest(s)to the accuracy and completeness of the information contained in this
Authorization Form and auftwize(s)the foregoing.
Signed this 2 nd day of___j avi u ar-T , 201,�,_r�
A«st 1'1psG1 _r :'l.' �� ....
Nam S9na
ypeC or Prnxed me turn -- —'- -
Address
Typed orPhmtedNam S: ure
Address
WITNESS:
MichaelMiiler
FurwV Ouedor Typed a Pmted Name Fun ral Directtx Sig" re
12463
Revwfa bn NurnOer
.loan M Ames
DOS-189844 (Rev.01110) Name of Deceased - -- Pave 3 of 3