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Ward, Howard Jr. Pii1C', View Cemetery & Cr(,inAorluill (,walker Road Queensbury, NY 12804 (.518) 745-4477 or (518) 745-4.476 Funeral Home Requested Relnrll 'I'll ie ---------- Name----------- o---- (,Kr�----JL�---------Case No -------s ------- t----------- Dale of Cremation--_I—P-06 "(,in1c Slartc(l �_��E1"�"I'1111C Completed_______ Placed in Hold: Placed in in Refrigeration: Placed in Retort: 1=?Mf 1 r Tme of Container ------------ M LUw{� f _ 0 ------------------cam{ L--&Jt4 r - Remarks --------------------- I Main ----------------------------------------- Move---------Z;Za— Place of Deatll---------�� --- �-� ---- ---�---5 --�rceC -- --�' 7g Estimated Weight of'Remains and Container--__-______ Date LZ rj 1111e RClllalllS al'rIVC(t at Cl'Clllatol'y___-____ -------AL A-------li •S0 _ ---- Name of Funeral Director or Reglstercd Resident. Delivering Remains___-- I Detwlcd reason for delay it remains were cremated more than /1-8 flours from tilllc of accepted delivery --------------------------------------- ----------------------------------- ---------------------------------------- Ret.ort Number in which Remains were crcnlatc(l_____________ Note:1'he Cremation Loh shall be rclillllcd 111 the Permanent Filc of the Crematory I I • New York State Depament of State NEW YORK DIVISION OF CEMETERIES STATE OF Division of OPPORTUNITY. Cemeteries One Commerce Plaza 99 Washington Avenue Albany,NY 12231-0001 Telephone:(518)474-6226 www.dos.ny.gov Authorization for Cremation and Disposition This Authorization Form must be completed and signed prior to delivery of remains for cremation. Date:8/15/19 Number: J 1'1 Crematory Name: Pine Yew Crematory 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. I 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 injure 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,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 I Name of Deceased:Howard C.Ward Jr. Marital Status:never married Last Known Address.218 Glen Eddy Dr., Niskayuna, NY 12309 Place of Death:Riley Hill Rd., Stony Creek, NY 12878 I Sex: ©M ❑ F Age:95 DOB:4/11/1924 Date of Death-8/13/2019 Estimated Weight: 140 Description of casket/container in which remains will be delivered. MacDonald Container basic cardboard cremation container PERSON IN CONTROL OF DISPOSITION (Person(s)in control of disposition, initial 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- 1/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 Itwe are the person(s)having priority under Public Health Law I Section 4201 and have the right to authorize cremation of the remains of the deceased. My/Our relationship to the deceased Is as follows: i Howard C.Ward,Jr. (Name orDewawd) DOS-1898-f(Rev.08/15) Page 1 of 3 i i Authorization for Cremation and Disposition (Insert from the list below) Number:7 Description:nephew 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 persgn(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 dose 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). (Initi I ALL THREE of the following) Mg%�k 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. lMe affirm that instructions have been given to Patricia Miller (Funeral DNedor Name) 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 (crematory Name) is not responsible for the 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 Pine View Crematory (cremerur Name) 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:Brewer Funeral Home, Inc.representitive Address:24 Church St., Lake Luzeme, NY 12846 Phone:518-696-2744 The cremated remains of deceased will be disposed of as follows: return to family for scattering 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 (Cnfmafory Name) the remains to Brewer Funeral Home, Inc. by delivery (Funeral Home Name) in person or by registered mail. Howard C.Ward, Jr. (Name of Dw""d) DOS-1898-f(Rev. 08/15) Page 2 of 3 Authorization for Cremation and Disposition (initial the following) A I/We understand that if the remains are not claimed within 120 days of cremation, Pine View Crematory may dispose of the remains in (Name of crema►ory) an irretrievable manner, such as by scattering. CREMATION CONTAINERIURN (ni. /ONE of the following) An um to be used as a container for the cremated remains has been purchased from Brewer Funeral Home, Inc. and is described as follows: 1/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- An urn is not yet purchased. INVe understand that if no um is purchased or otherwise provided Pine View Crematory will place the cremated remains in (Name of crematory) a rigid temporary container for delivery. This Authorization Form was provided by Patricia Miller was executed at (Funeral Director Name) Brewer Funeral Home, Inc. (Funeral Home Name) 24 Church St.,Lake Luzeme,NY 12846. (Funeral Hone 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 Authorization Form,attest(s) to the accuracy and completeness of the information contained In this Authorization Form and authorize(s)the foregoing. Signed this _16 day of •20--�— - Ned Simpson A& -C �•""t'--� Typed or Printed Name Signature 42 Watkins Dr.,Sandy Hook,CT 06482 Address Typed or Printed Name nature MOWN Typed or Printed Nome Signature Address WITNESS: t` Patricia Miller �a— (Funeral Director Typed or Printed Norm) (Funeral Director Signature) 12465 Numbeo Howard C.Ward,Jr. (Name Of Deceased) DOS-1898-f(Rev. 08/15) Page 3 of 3