Bartlett, William I:III(Acq l\ �,I l'111.11(>I'llllll
49
I);Ilc nl (..I(:Illallnl l 1�7� -
�l-g. ./� I rrrlr- '�r.n lrrl A�Ay I IIIII ( .r)IIIIIIt'I(_'rl
Ph(cd III I Irllrl: D9S0 �`'1
I'Lu ccl III II( I I I;,t:l ,II It)I I �JS�M 'til •-5^-� 9
I'In(t.11 ul ISt:I(nl. ���j/�,dl
•I�)•),�: ()I (,:t)Ill;lillc:l �'IpreH.�e 4G,stl[.e.� �dYri an C���iGh G,�p�,/•a�l�.�
Ilrl•1111 ....Q7Y�/�Ayl - .--
I'I„tl tll I)�all1 -
y
I.\IIIILII('(I \'\�CI;;III (11 I(('Ill:llll\ ,111(i ( (nll.nllt I
I),II� (� I Illlt' I(t III,ul1� ;n'I Irc.rl ,II (,It In.Ilru)• S 4� -
� 31D
iv;llll� ,>I I Ilu�l,ll 17I IC( Ic>r r�l' li(';;r,lt l r'rl Rr ,ult lu ( lt;lil t l III )
�ll�llllll Il:a;<)11 IOI (Il�l.l)' il� il:l)1,IIII'� tvl Il I. II I�.Ill�ll Illllll :Il.11l •I�r, I
1(II1'(I) II lit II 111111
._.._.__ UI .Il It IIIt:I
Itl�l Ull NIII III II'I� III \VIM II I�l'111.1111•. ,\'I t. � _. .. _
I V(Ill' I II(' (.I l'111.111(111 I .(1;� \I 1.111 Ill• Il'I IIIII 11 � _ -
NYS Department of State
Authorization for Cremation and Disposition Division of Cemeteries
One Commerce Plaza,99 Washington Avenue
Albany, NY 12231
(518)474-6226
www.dos.state.ny.us
This Authorization Form must be completed and signed prior to delivery of remains for cremation.
Date:APRIL 5, 2019 Number:2019-015
Crematory Name:PINE VIEW CREMATORIUM
Address:QUAKER 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,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 urn. Cremated remains generally are pulverized until no single fragment is
recognizable as skeletal tissue.
OPENING OF 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 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.
IDENTIFICATION OF DECEASED
Name of Deceased:WILLIAM H. BARTLETT Marital Status:MARRIED
Last Known Address:26 MEADOWBROOK COURT GUILDERLAND, NY 12084
I
Place of Death:DAUGHTERS OF SARAH NURSING CENTER ALBANY,NY
Sex: OM OF Age:81 DOB:07/31/1937 Date of Death:04/04/2019 Estimated Weight:180
Description of casketicontainer in which remains will be delivered: j
FLORENCE CASKET COMPANY/CREMATION CONTAINER/FIBERBOARD
PERSON IN CONTROL OF DISPOSITION
(Person(s)in control of disposition, ini ' 1 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.
-OR-
I
VS— 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 (continued next page) j
WILLIAM H.BARTLETT
DOS-1898-f-I (Rev.01110) Name of Deceased Page 1 of 3
tam/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 list below)
Number: Description: SPOUSEIWIFE
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 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 §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 §4201(7).
ni ial ALL THREE of the following)
I Go i 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 ematory personnel.
/' I/We hereby affirm that instructions have been given to (funeraldirectorname)JAMES P. McDERMOTT
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. (crematory name)PINE VIEW CREMATORIUM 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.
I/We hereby authorize (crematoryname)PINE VIEW CREMATORIUM 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:JAMES P. MCDERMOTT
I
Address:9 PINE ST CHESTERTOWN,NY 12817 Phone:518-494-2811
The cremated remains of deceased will be disposed of as follows:
II
INTER AT CHESTER RURAL CEMETERY CHESTERTOWN,NY 12817
If for any reason the person named above does not take possession of the cremated remains,
(crematoryname)PINE VIEW CREMATORIUM is authorized to give possession of the remains to
(funeralhomename)BARTON-MCDERMOTT FUNERAL HOME,INC. by delivery in person or by registered mail.
WILLIAM H.BARTLETT
DOS-1898-f-I (Rev.01/10) Name of Deceased Page 2 of 3
Z"O` +N OF QUEEN5BUr�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director ,,3-v,c ,e
Name W ,����,,� I }c,r Case# I`��i
Date Of Cremation
Time Cremation Started A
Time Cremation Completed_ 0 U
Type of Container
Remarks
- 4�"�
Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road, Queensbury, New York, 12804
Cemetery Office: (518) 745-4476, Crematorium: (518) 745-4477
Authorization to Cremate
The undersigned requests and authorizes Pine View Crematorium,in accordance with and subject to its Rules and Regulations to
cremate the remains of.
LJ II ; G _ &,,,4, �a1z
(Name) /� (Sex)
' h 6 err R-- r. S . l /�
(Street (City) (State) (Zip Code)
who died on y�- day of 20 06
at 1\ e
—(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
v f: P4".
(► a ) ( )
Relationship to the deceased L)
7
Name of Funeral Home 'C S nno r(a-
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or no)pacemaker fibrillator or arty other battery operated
device In his or her body. (Circle One)
I certify that I have full power and authorization to arrange for the cremation of the remains and to direct the disposition of the
cremated remains,that any personal Possessions have either been removed or may be destroyed,and agree to protect,defend and
save harmless Pine View Crematorium from any and all claims and demands for loss or damages which may be made against them
by reason of or connected with the cremation of said remains as directed,whether such claims or demands are or are not wholly
rfa fraudu _ , l
7 0`. . r T vZ.2
(wlt (Address)
`, c
(SI Cature and Address of Relative or Legal Representative)
Signed on this date: a 0 0 L
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify:
If pulverization of cremated remains is requested,check here
Revision:January 1,2006
C ,
nitial the following)
I/We understand that if the remains are not claimed within 120 days of cremation,
(crematory name)PINE VIEW CREMATORIUM may dispose of the remains in an irretrievable manner,
such as by scattering.
CREMATION CONTAINER/URN
(Ini i l ONE of the following)
11�L�- An um to be used as a container for the cremated remains has been purchased from
BARTON-McDERMOTT FUNERAL HOME,INC and is described as follows:
OAK URN
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-
An urn has not yet been purchased. I/We understand that if no urn is purchased or otherwise provided
Nrematoryname) PINE VIEW CREMATORIUM will place the cremated remains in a rigid temporary
container for delivery.
This Authorization Form was provided by (funeral directorname)JAMES P. MCDERMOTT
was executed at(funeral home name)BARTON-MCD E RM OTT FUNERAL HOME,INC.
(funeral home address)9 PINE ST CHESTERTOWN,NY 12817 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 is/are 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 authorize(s)the foregoing.
Signed this 5TH a day of APRIL . 20 19
WANDA BARTLETT
Typed or Printed Name gn ure
26 MEADOWBROOK COURT GUILDERLAND,NY 12084
Address
Typed or Printed Name Signature
Address
Typed or Printed Name Signature
Address
WITNESS:
JAMES P. McDERMOTT
Funeral Director Typed or Printed Name era/Director Sig ature
12330
Registration Number
WILLIAM H. BARTLETT
DOS-1898-f-I (Rev.01i10) Name of Deceased Page 3 of 3