Fowler, Cynthia Pine View Ce;llictery & CrelTIA0 1-1u111
(,quaker Road
Queensbury, NY 12804
(.518) 745-4477 or (518) 74.5-4476
Funeral Honk
Requested Retul•n `l'iule
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Name----------- - 4A I.c---- ° ��
-- �-----------------Case No• --------�-��-
Date of Crenlalion____ $L9 �►� 'f role SLarte(t_7 ln�l'�_'['1I11C C011ll)ICIC(I-_______
Placed in Hold:
Placed in in Refrigeration: _--
Placed in Retort:
"I'yI)c of Container------ --�1`-'-- ' - �4 -
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Remarks
Main ----------------------------------------- Move---------- =ii-Allt--- sMn
Place Of Dealll-------- "----------p�k -------
Emiillat.ed Weight of'Remains and Containcr
-----------1g1)
Date LZ.rhinic Remains arrived at CrenlaLory..................... Tod��_--
Name of Funeral Director or Registered Resident. Delivering Remains___-_hs,1c �4d/s4—
Dctailcd reason for delay it remains, were crelllat.Cd morc than 11.8 hours frolll tulle of accepted
delivery
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Retort Number in which Remains were crcluated___________�u�F-�C
Note:'hhe Cremation Log shall be rewlicd I11 (lie Permanent File of(lie Crematory
Ws Department of state
Authorization for Cremation and Disposition won of cemeteries
one commeroe Plaza.99�Avenue
(M)474-=6
wwwAos.state.ny.us
- and signed pdor
This Autfwrizatfon Form must be completed to delivery of remafi►s for cnemaaon.
Date: c9 SS �/ Number:
Crematory Name: IF``)
Address: can DiJ Phone:,�l�
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 wig be disposed of as
required by law.The cremated remains will be mechanically pulverized into small pieces and placed into a
designated container or tim. Cremated remains generally are pulverized until no single fragment is
irecognizable 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.
�ENTIFIGATION OF DE EASED XL&ee- " `�'0140
'/ Marital Status:.,
Name of Deceased: OC �c -4c�C �-
Last Known Address: @
LA
Place of Death:-
Date of Death: S� 1 / Estimated Weight: f
Sex: Elm 5(F Age: DOB: f1
Description of casketicontairter in which remains will be delivered:
Y�e,U�Yltl �r�
pERsON INC INMOL OF DID OSITION
(Person(s)in control of disp03160n, ONE of the following)
1 am/We are the designated agent of the dec eased designated in a will or written instrument executed
pursuant to Public Health Law section 4201.
-OR-
�— IMfe 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 POP)
Nsnte of Deceased Page 1 of 3
ppS.tg98-f-1 (Rev.01/10)
'I dm/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. 7 Description: x)
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 behaff of the deceased and who has executed a written statement
pursuant to Public Health Law§4201(7).
E
L THREE of the following)
IM/e hereby affirm that the body of the deceased does not contain a battery, battery pack, power cell,
ve implant,or radioactive device and that any such materials were removed prior to the execution of this
ation Form. Failure to remove these items prior to cremation may result in harm to the crematory and
crematory personnel.
IMIe hereby affirm that instructions have been given to(funerw&vcwname) l�
r rding the removal of any personal property or other thing o4alue which any pe n signing below or any family
member of the deceased wishes to preserve. (awwtay name) f*/AP&-61&� [�k1✓P7h �'gL,!-/ 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.
ZE UWe hereby authorize(awneoyname) / ' 11L)Lo (£&J A:7 emu'u' to cremate the
�r arns of the deceased.
FINAL DISPOSITION ••
The person auth rued to recei the cremated remains of the deceased from the crematory is:
Name: die R 0 ✓
Address: J3� GU SLR�' l,� oL�iU� �� /� 7 /��0 Phone: SKS �XJ'L3 2
The cremated remains of deceased will be disposed of as follows:
If for any reason person named above does not take possession of the cremated remains,
(crematory name) ew z-CIf A- J �c'fi>ara.2 tc�i is authorized to give possession of the remains to
(fun"twine name) by delivery in person or by regi mail.
9.a .L--1 kiLlE& , ,
DOS-189844 (Rev.01110) Name of sad Page 2 of 3
y
UWe und�tand that if the remain�ae ot daimed within 120 days of cremation,
it��f c� C f J7 y �1 may dispose of the remains in an irretrievable manner,
as by scattering. '
CREMATION CONTAINERIURN
(LaffW ONE of the Wowing)
An um to be used as a container for the cremated remains has been purchased from
and is described as follows:
INVe understand that N the urn is too small to hold the entire cremated remains,an additional rigid container may be
used for delivery.
-OR
c An ums not yet been purchased. I/We understand that if no um is purchased or otherwise provided
( name) /�t)i t will place the cremated remains in a rigid temporary
tainer for delivery.
This Authorization Form was provid6;y(furw t drectorname) '�'� P'z
was executed at(funeral home nerve) '
(runeral►wine add►a8s)
nd is signed by the funeral director
as witness to its execution.
I/We have received a completed copy of this Authorization Form.
The persons)identified below islare the persm(s)in control of disposition,who by signing this
Authorization Form,attest(s)to the accuracy and cornpletwiess of the information contained in this
Authorization Form and aythorize(s)th foregoing.
Signed this day of % 2Q
Typed or Printed N
Address
Typed or Pfnted Name Signature
Address
Typed or Printed Name signeture
Address
WiT ESS
Funeral CWk9cW T or Printed Name Funeral arector
Registration Number /
ppr,,.lggg..t-I (Rev.01H0)
Name of Decessed Page 3 of 3