Matthews, John Pine VICW CCn1et.C1'y & CI-elll�LLorlulll
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4,4,76
Fullcral Honk
Ruluested Return "I'iule
----------
Name--------- °
---------------------C.Ise No. ___-- 57�1
Dille of Cremation--_LVI)i __rrinic Slartalg _-_I`lil1C ColllpICIC(L IZ: D j
Placed in Hold:
Placed ill in Re ngeralion:
Placed in Retort:
-I'ypc of Cont<liner f--------
---------------------------------------------------------------------------------
Remarks
--------------------- Q Main Move------------��- -/-1t_II
Place of Death--------Jort soy. IP-AAr
Estimated Weight of*Remains and Containcr_________��6____
DaLe vrinic Relllalns arrived at.CrclllaLol'y_
------------------
Name of funeral Director or Registered Resident Delivering Remains------Rorll e_
Detvlcd reason for delay if remains were crema(ed more than /48 hours from time of accepted
delivery
---------------------------------------------------
-----------------------------------------------------------------------------------
Retort Number in which Remains were crcnialc(I______
----�ca /l.--- ---
Note:'l'hc CI'ellklLi011 I,og shall he retainc(I in (llc PCI'111a11CI1L I"')c o('the Crematory
New York State
Department of State
NEW PORK Division Of DIVISION OF CEMETERIES
STATE OF One Commerce Plaza
OPPORTUNITY. Cemeteries
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: 08/29/2019 Number: S77
Crematory Name: Pine View Crematorium
Address: 51 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 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
Name of Deceased: John P. Matthews Marital status: Married
Last Known Address: 18 Cedar Point, Lake George, NY 12845
Place of Death: Fort Hudson Nursing Home, 319 Upper Broadway, Fort Edward, NY 12828
Sex: ®M OF Age: 75 DOB: 02/09/1944 Date of Death: 08/28/2019 Estimated Wei ht: i l 0-
Description of casket/container in which remains will be delivered.
Corrugated Cardboard D04:!�l'D 634f
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
Section 4201.
-OR-
I/)anhave
have no knowledge that the deceased executed a written instrument pursuant to Public Health Law Section 4201 or a
will contai gctions for the disposition of his or her remains and Itwe are the person(s) having priority under Public Health Law
Section 4201 the right to authorize cremation of the remains of the deceased. My/Our relationship to the deceased is as
follows:
John P. Matthews
(Name of Deceased)
DOS-1898-f(Rev. 08/15) Page 1 of 3
1
Authorization for Cremation and Disposition
(Insert from the list below)
Number: 2 Description: Spouse
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. er person who is acting on behalf of the deceased and who has executed a written statement pursuant to Public Health
Law Se on 4201(7).
(Initial ALL THR E of the following)
I hereby affirm that the body of the deceased does not contain a battery, battery pack, power cell, radioactive implant,
or radioa ' e device and that any such materials were removed prior to the execution of this Authorization Form. Failure to remove
t items for to cremation may result in harm to the crematory and crematory personnel.
I= affirm that instructions have been given to TFfflMl Dr~Nerr*)
rega'rdidi'nggtt removal of any personal property or other thing of value whic y person signing below or any family member of the
d ed wishes to preserve. Pine View Crematorium
(Cram wy Na—)
is not responsible for the removal of personal items from the container or from the remains of the deceased. Personal items left in the
c ntainer or w h the remains will be destroyed by the cremation process and cannot be retrieved after cremation.
�IIW hereby authorize Pine View Crematorium
(Crematory Na—)
t e the remains of the deceased.
FINAL DISPOSITION
The person authorized to receive the cremated remains of the deceased from the crematory is:
Name: Diane Matthews
Address: 18 Cedar Point, Lake George, NY 12845- Phone:
The cremated remains of deceased will be disposed of as follows:
Return to family
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
(Cremetay Na—)
the remains to Singleton Sullivan Potter Funeral Home by delivery
(Funeral Home Name)
in person or by registered mail.
John P. Matthews
(Name of Deceased)
DOS-1898-f(Rev. 08/15) Page 2 of 3
ca :able
horization for Cremation and Disposition
wi
Ve derstand that if the remains are not claimed within 120 days of cremation,
Pine View Crematorium may dispose of the remains in
(Name of Crematory)
manner, such as by scattering.
CREMATION CONTAINERIURN
(Initial ONE of the following)
Singleton Sullivan Potter
An urn to be used as a container for the cremated remains has been purchased from G„nmrol ur%mo
and is described as follows:
I 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 rn is not yet purchased. INVe understand that if no urn is purchased or otherwise provided
Pine View Crematorium will place the cremated remains in
C)
(Name of CrematarY)
a rigid temporary container for delivery. KLM544—"
This Authorization Form was provided by
�ZA was executed at
(F neral Director Name)
Singleton Sullivan er Funeral Home
(Funeral Home Name)
407 Bay Road, Queensbury, NY 12804
(Funeral Home Address)
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 islare 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 29th day of August ,
DianjMatthews
Typed or Printed Name
18 Cedar Point, Lake George, NY 1 45-
Address
Typed or PYinied Name Signature
Address
Typed or Phnted Name Signature
Address
NESS:
Director Ty or inted Name) (Funeral Drector Signature)
(Reglbtranon O°1
John P. Matthews
(Name of Deceased)
DOS-1898-f(Rev. 08/15) Page 3 of 3