The URL can be used to link to this page

Burritt, Merton Pine View Celli( Lery & CrelTiatorlulll Quaker Road Queensbury, NY 12804 (518) 745-4477 or (518) 745-4476 Funeral Home Requested Return 1'iulc__________ Name------kaq� ^----Ncrllf---------------------Case No. --------539 Date of Cremation __g Sj j5___"rime Staocdy_4 Time C011l[)ICIC(1_____I�_"►S Placed in Hold: 7—-- Placed in Refrigeration: Placed in Retort: 1O_00 A Type of Container _____--�Iurtnr�___Gkr►44i� __vnt}---�n---��co!' rvrl,� �_I ----------------------------------------------------------------------------- Remarks --------------------- Main -------- Move-------- _—/D --------------------------------- -- Place oC Dcal11____—�� fiy____------ Estimated Weight.of Rcmalns and ContaineC 0 I.� `` ------- -------------------- Date&'rime Remains arrived at Crematory------------------ I11______2'�� Name of Funcral Director or Registered Resident. Delivering RenialliS___---+°w- __-- Dctwlcd reason for delay if remains were cremated Vlore than 48 hours, from (Ime of accepted delivery ----------------------------------------------------------------------------- --------------------------------------------------------------------------- Ret.ort Number in which Remains were crematcdSqpf(t Note:'['lie Cremation I,og shall be retained Ill tllc Pci-mancut. File of the Crematory ^ ' J New York State NEW YORK Department of State Division of DIVISION OF CEMETERIES STATE OF One Commerce Plaza OPPORTUNITY_ Cemeteries 99 Washington Avenue Albany,NY 12231-0001 Telephone:(518)4746226 www.clos.ny.gov Authorization for Cremation and Disposition This Authorization Form must be completed and signed prior to delivery of remains for cremation. Date. 8�14(!ti Number. 5 g Crematory Name:Pine View Crematory ` ,^ Address: 1 O UAO-A (?per QuiF,nt l.�Djg?l 1�+�1 - 174 J Phone: CREMATION 1S 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 same minimal dust and residue will Waly be)eft behind. The crematory tW)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. Cremates 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 N enclosed which might injure employees or damage the crematory property. if human remain 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 DECEASED Name of Deceased:__e4-I d I J - & t Marital States: i "i�y, p r r i.er Last Known Address:--�g<? 60 •r P A-S W A Qu e.e)06 L L,/-4 1�-IX ' 1?,J ff Place of Death: Q-�O-@vS wAY' Adeeij.54urK /q Y �Z Sex: MAI ❑F Age:j DOB. o,5--If- Date of Death. ©Gf�� - o�/� Estimated Weight: Description of casket/container in which remains will be delivered. � toi-eµ%C e- (?1^Q-r.-1 ATG0 C)/U1 °�r' PO ' 'A-TZ PERSON IN CONTROL OF DISPOSITION (Person(s)in control of dsposition,initial ONE of the fUlowing) 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. R I/We have no knowledge that the deceased executed a written instrument pursuant to Public Health Law Section 4201 or a wilI containing directions for the disposition of his or her remains and Uwe 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: /.�` a ra-; / iNeme dD DOS-1898-f(Rev.08/15) Page 1 of 3 Authorization for Cremation and Disposition pnawtfrom me ristbaiow) Number., Description: .�UrUali! 1. A Person designated in writing pursuant to Public Health Law Section 4201(3); 2. The surviving spouse; 2a. The survtving domestic partner, 3- Any 3urvhdn9 child eigtfieen years of age or older; 4. A surviving parent & A surviving sibling eighteen yeas of age or older, B. A iewfu[ly appointed guardian; 7. Any persons)eighteen years of age or older entitled to share in the estate and who Were closest in relationship to the deceased; 8. A duty appointed fiduciary of the estate; 9. A dose friend or relative who has executed a writhen statement pursuant to Public Health Law Section 4201(7); 10. A chief fiscal officer of a county or a public administrator appointed pursuaM to ttre sumo WO 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)_ THREE Of the following) Me 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 AuthorizWon Form. Failure to remove these tt9w prior to cremation may result In harm to the crematory and crematory personnel. IIWe affirm that Instructions have been given to (� 4A-) 4 l regarding the removal of any perb'o W property or offer thing of value which any person signing below or any family member of the deceased wishes to preserve. Pine View Crematory 9*M8bY"MOW is not responsible for the removal of personal items from the miner or from the remains of the deceased. Personal sterns left In the container or with the remains will be destroyed by the cremation process and cannot be retrieved after cremation. UWe hereby authorize Pine View Crematory to cremate the remains of the deceased. I FINAL DIS['OSMON The Person authorized to receive the cremated remains of the deceased from the dory Is: Name:Any Staff from the Edward L Kelly Funeral Home Address:1019 US Rt 9 PO Box 548,Sduoon Lake,NY 12870 Phone:518-532-7177 The cremated remains of deceased will be disposed-of as fdlo%w- e7c�r' 16 1-p mi l3orri 7ri0poly) If for any reason the person named above does not talm possession of the cremated remains, Pine View Crematory is authorized to give possession of the remains to Edward L Kelly Funeral Home r'WMW; by delivery in person or by registered mail. �'l e r ly i2 Ov �-t 7T' PWWWO DOS-1898-f(Rev.=15) Page 2 of 3 Authorization for Cremation and Disposition n" following) Me understand that if the remains are not claimed within 120 days of cremation, Pine View Crematory may dispose of the remains in (AW-orCrarnabry) an irretrievable manner,such as by scattering. CREMATION CONTAINERIURN 1;X the following) 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_ (] ,�K p�/� C�. Me understand that if the um is too small to hold the entire cremated remains,an additional rigid container may be used for delivery. -OR- urn um is not yet purchased. WVe understand o um is purcha rwise provided TAi ,�I cfemated remains in (Name Of C—M ow a rigid temporary container for delivery_ This Authorization Form was provided by d �'f was executed at (Fur&.+ral DirecODr(Vame) Edward L Kelly Funeral Home 1019 US RL 9,PO Box 548 Schroon Lake,NY 12870 (l~aMW Ham Name) (Funeral Fbme Address) and is signed by the funeral director as witness to its execution. INVe 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 AuthorftWon Form,attests) to the accuracy and completeness of the information contained in this Audhoraafion Form and authorh*s)the foregoing. Signed this day of ,20 Lbur J Typworpmwffaw Poor= Typed arPMW Name Address Typed or PIMIW M= so aft— AOMM WITNESS: / 6 rwpera(DireaorTypedorPftWAbme) I (Furreraf Sryr>ature) r (/R a INmeo< DOS-1898-f(Rev.08/15) Page 3 of 3