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Keech, Richard Pipe View Cenlcaery & CreillatorlulTl (,quaker Road Queensbury, NY 12804 (518) 745-4477 or (518) 745-4.4-76 Funeral Hollle } Requested Return `l'inle Nanlc-------- "�`' ----��ttL------------------Case No ---------- s�L Dale of Cremation_- Time Colllplctc(l._______ Placed in Hold: Placed ill in Refrigeration: -__- Placed in Retort: "I'ype of Containerr----------�!A4A4 cv%40 --- "x----- wo®e -- _- --- - --------- --------------------- ------- ��ri�b,�� ----- Remarks --------------------- Mails ----------------------------------------- Move--------------$ r�� - ''� Place of Death------------Fd�T AF,,h1,T11 Estimated WClght of'Remains and Container-------------���_ (DS --_--__--- Date&Time Remains arrived at Crematory___---- 44 01�_ f Name of Funeral Director or Registered Resident Delivering Remains__ 4I 161(j_ 3: z00M Detailed reason for delay II remains-were cremated inore than 48 hours from time of accepted delivery -------------------- ----- �----� " ----------------------------------- ---------------------- a'- ----0 rJ�--- --W FA 04 --- ----------------- Retort Number in which Remains were cremated Note:,rile crelllatloll I,og shall be rctalncd ill the Pcl'niancilt File of the Crematory New York State Department of State NEWYORK ©�v�c..� Q� (f DIVIStONOFCEMETERIES One Commerce Plaza STATE OF 99 Washington Avenue OPPORTUNITY- Cemeteries Albany,NY 1 2 2 31-0001 Telephone:(S18)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: 11161111 Number: 5%4b 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. able efforts to remove all of the remains and other material from the cremation Following cremation,the crematory will take reason ely be left behind.The crematory will separate incidental and foreign material from chamber,but some minimal dust and residue will lik 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 THE CONTAINER The crematory may only open the container holding the un-cremated human remains in limited circumstances,such as to confirm the If identity of the deceased or to ensure that no material is enclosed which might injure employees or damage the crematory property. 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 Name of Deceased: Richard Allen Keech Marital Status: �'�T L• ✓�+--�� Last Known Address: Fort Hudson HCF 319 Broadwa Fort Edward NY 12828 Place of Death: FORT HUDSON HEALTH CARE FAC Upper Broadway Fort Edward NY Sex:0 M ❑ F Age: 79 DOB: 07/03/1940 Date of Death: 08/14/2(l19 Estimated Weight: Description of casket/container in which remains will be delivered. ads Cep � pl_� � ��� CONTROL n(.� PERSON IN CO (Person(s)in control of disposition, initial ONE of the following) Ci I am/We are the designated agent of the deceased designated in a will or written instrument executed pursuant to Public ealth Law Section 4201. -OR 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 Allen Keech (Name of Deceased) DOS-1898-f(Rev. 08/15) Page 1 of 3 Authorization for Cremation and Disposition (Insert from the list below) Number: > Description: 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 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). (Init ial 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, r� 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/We affirm that instructions have been given to Paul M. Dietrich (Funeral Director 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 Crematorium (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. j I I/We hereby authorize Pine View Crematorium (Crematory 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: (L`�� F V 1-Vv f � Name: / •.v S 0 /�..��� (� � o�1e/ Address: MW4 -5 The cremated remains of deceased w(ll be disposed of as follows: '3 Uvi (D" Ce�—VCC4 I Z.ciev+ - VN IZ 0 If for any reason the person named above does not take possession of the cremated remains, Pine View Crematorium is authorized to give possession of (Crematory Name) the remains to Carleton Funeral Home Inc. by delivery (Funeral Home Name) in person or by registered mail. Richard Allen Keech (Name of Deceased) DOS-1898-f(Rev.08/15) Page 2 of 3 I Authorization for Cremation and Disposition (Initial the ollowing) I/We understand that if the remains are not claimed within 120 days of cremation, Pine View Crematorium may dispose of the remains in an irretrievable manner, such as by scattering. (Name of Crematory) CREMATION CONTAINER/URN (Initial ONE ot the ollowing) An urn to be used papcontainer(fo�r the cremated remains has been purchased from and is escribed as follows: `^— `' t-t/ 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 is not yet purchased. I/We understand that if no urn is purchased or otherwise provided Pine View Crematorium will place the cremated remains in (Name of Creme ory a rigid temporary container for delivery. This Authorization Form was provided by Paul M. Dietrich was executed at (Funeral Director Name) Carleton Funeral Home, Inc. (Funeral HomeName) 68 Main St. P. O. Box 67 Hudson Falls NY 12839 unera ome ress 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 15 day of August 120 19 Typed or lilt igna ure tom- 15 Address Signature Typed or Printed Name Address Signature Typed or Printed Name Address WITNESS: Paul M. Dietrich Funeralype r gn e ame unera i or gn egis wn um e` ra r) rC\/J, Richard Allen Keech ame o ecease Page 3 of 3 DOS-1898-f(Rev. 08/15)