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Harrison, Richard f � I'ittc \11 v C:ctltctci y & C:rciII;tt( t•iunt (>tt;tkcr 11(m l Ouccnshuty, NY 1280/1, 0 18) 741)-4/1,77 or O 18) 74,5-411,76' I:trttcr;tl I-lontc kcclucsiccl Rcltun I iinc Ind N;unc------ 1� '--- 'ff�•T 'SLY - C;isc No. -�-Z J.�.�. I`iillc ,��,ulccl_._... _,�. uilc C;ompiciccl- Phc'ccl it) Hold: Pkwcd in 1lclrigci.mon: __-....-c ___. ..... 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Date:Jan. 18,2019 Number:_ (� Crematory Name:Pine View Crematory Address. Road,Queensbury,NY 12804 Phone: 518-745-4477 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,i 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 1 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 iniure 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,tie 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: Richard J.Harrison Marital Status: Widowed Last Known Address:3230 Church Street,Valatle,NY 12184 Piave of Death:3230 Church Street,Valatie,NY 12184 Sex: ■M [3 F Age:93 DOB: 06128/1925 Date of Death:01/17/2019 Estimated Weight: 160 Description of casket/container in which remains will be delivered. Minimum Cremation Casket,Florence Casket Co.Cardboard/pine PERSON IN CONTROL OF DISPOSITION (Persrri r)in control of disposition,initial ONE of the following) r' — 1 am/We are the designated agent of the deceased designated in a will or written Instrument executed pursuant to Public Health Law Section 4201. n— 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: . Richard J.Harrison !Marne a'Decease I DOS-1898-f(Rev.08/15) Page 1 of 3 I . . I Authorization for Cremation and Disposition (insert from the list Wow) Number. 3 Description:Any surviving child eighteen years of age or older 1. A person designated in writing pursuant to Public Health Law Section 4201(3); 2- The 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 islare closest In relationship to the deceased; S. 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). (ln ft l 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. I _r- I/We affirm that instructions have been given to Todd G.Kilmer (Fwwaf 09�:a 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. Pine View Crematory is not responsible for the removal of personal items from the container or from the remains of the deceased. Personal hams left In the container or with the remains will be destroyed by the cremation process and cannot be retrieved after cremation. �f V Me hereby authorize Pine View Crematory ` lamer , to cremate the remains of the deceased. FINAL DISPOSITION The person authorized to receive the cremated remains of the deceased from the crematory is: Name:M.B.Kilmer Funeral Home Address:82 Broadway,Fort Edward,NY 12828 Phone: 518-747-9266 The cremated remains of deceased will be disposed of as follows: Interment in Memory Gardens i 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 ( Y N—) - the remains to M.B.Kilmer Funeral Horne by delivery (Furw.a rion,s+veins) in person or by registered mail. Richard J.Harrison (lime or oecessee) DOS-1898-f(Rev.08/15) Page 2 of 3 Authorization for Cremation and Disposition ( the following) I/We understand that if the remains are not claimed within 120 days of cremation, Pine View Crematory (Nme Of cremator! ma disp ose pose of the remains in an irretrievable manner,such as by scattering. CREMATION CONTAINERAMN (lam ONE of the following) An um to be used as a container for the cremated remains has been purchased from M.B.Kilmer Funeral Home and is described as follows.- I/We understand that if the um is too small to hold the enpre Cremated remains,an additional rigid container may be used for delivery. -OR- An um is not yet purchased. I/We understand that if no um is purchased or otherwise provided Pine View Crematory will place the cremated remains in t of c+e r) a rigid temporary container for delivery. This Autdori Todd G.Kilmerzaftn Form was provided by was executed.at rruxvetD,ecrcr)M—) M.B.Kilmer Funeral Home 82 Broadway,Fort Edward,NY 12828 rWWW mom A ) tF,r,e ar r+—aditso 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 bellow islare the person(s)in conbvi of disposition,who by signing this Aufhorizadon Form,attest(s) to the accuracy and completeness of the information contained In this Authorization Form and authorizes)the foregoing. Signed this 18th day of January 20 19 Kathleen Fuller rywd w vdroedNanw 9 Debbie Court,Albany,NY 12205 T,vedw Mane Adams Typed ar a~name s+ Adaeaa WITNESS: Todd G. Kilmer Digitally sigried by Todd G.IGlmer Todd G.Kilmer Daft:2019.01.18 11:59.48-05'00' FFenerat D#*dw Typed w PhfNed Name) eV-9 D tdor Sfpntl") 11897 Richard J.Harrison ' iNama orOaaasa� DOS-1898-f(Rev.08115) Page 3 of 3