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Moumblo, Lester r* I ine Vices Cenlel:ery & Cl-Cl T1ato1-1UIII Quaker Road Queensbury, NY 12804 (518) 745-4477 or (518) 74,5-zl,4,76 f uncral Ho111C ------- �( - Rccfuestecl Re:tunl 'f'ilne_ 1 �_ ��. Name- -------- � f---- 4��►.� --�Q----------------- -Case No. S Date of Cre lliation_ _� lQ___ f'inle Startccl-6 3 lM-hme Compicic(l._/D __..3fJ�r✓1 ----------- Placed in I-Iold: ----------------- Placed in Refrigeration: Placed in Retort: _-a73 A? --- Type of contalllet' ------------------ Remarks �I Main -__--(>7`7Ul�Nn__ - ------------------ ------ Move------v-�-��n_'1------------ Estimated Weigill ol' Remains and C.olltaillel' /DV Date&Time Remains arrived al CI-erliator p Name of Funeral Director or Rcbistcrcd Resident Delivering Renlains___ eft___ trc�er� Detwlcd reason for delay if remains were cremated morc (hall 48 llOUl'S (C0111 t1111C of accci cd delivery ------------------------------------------------------------------------------ Retort Number in which Remains were cremated_ dl,J s Pa Note:'hlle CI'cmauoR I.o shall be retainc(I in the Permanent Filc ol'the Crematory Authorization for Cremation and Dispositioi) NYS Deparlment of Slate i Division of cemeteries One Commerce Plaza,99 Washington Avenue Albany,NY 12231 (518)474-6226 www.dos.state.ny.us This Authorization Form must be completed and signed prior to delivery of remains for cremation. Date: Number S$ Crematory Name: Pine View Crematorium Address: Qualcer Road, Queensbury,NY 12804 Phone: CREMATION IS AN IRREVERSIBLE AND FINAL PROCES,5. 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 heal:bnd flame. The heat and flame will incinerate and consume everything except bone and metal, which are a;1 that will be left after cremation. Following cremation, the crematory will take reasonable effor.s 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 materibi will be disposed of as required by law. The cremated remains will be mechanically Ir'ulverized into small pieces and placed into a designated container or urn; Cremated remains generally ri re pulverized until no single fragment is recognizable as skeletal tissue. OPENING OF CONTAINER. The crematory may only open the container holding the un-cr(:.E'nated 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 delivere(:) in a container which is not suitable for cremation such as a ceremonial or rental casket, the crematory will requree that the remains be moved into a suitable container before it accepts the remains. The opening of a c;)ntainer or the transfer or removal of remains will be conducted before a witness and will be done in privacy, with c!gnity and respect. IDENTIFICATION OF DECEASED Name of Deceased: _C....eS+:�r,- S, V✓1 yh jy� Marital Status: /M cc V11;11 r) Last Known Address: Lt .4 �7T W\Ilz Sol ►/l �3 Place of Death: 10 t-t -'7 14Lcl;�Ckl J( - (' Z J-3 9 Se M F Age: Iy 1 DOB: q ) Dat,: of Death: ��( Estimated Weight: f oe2l—�J Description of casket/container in which remains will be delive;ed: 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. -OR- . I/We have no knowledge that the deceased executcl a written instrument pursuant to Public Health Law section 4201 or a will containing directions for the disposition if his or her remains and� (Continued next page) DOS-1898-f-I(Rev.01110) Name of Deceased Page 1 of 3 ,I arrj we are the person(s) having priority under Public Heal.,h 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: 2 Description: �v L& 1. A person designated in writing pursuant to Public H alth 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 adminis rator appointed pursuant to the Surrogate's Court Procedure Act; 1 Oa.Any other person who is acting on behalf of the c:eceased and who has e ecuted a written statement pursuant to Public Health Law §4201(7) (Initial ALL THREE of the following) �( ✓� INVe hereby affirm that the body of the deceased, does not contain a battery, battery pack, power cell, 1 radioactive implant, or radioactive device and that any suc 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. g�INVe hereby affirm that instructions have been gken to (funeral director name) g the removal of any personal property or other thing of value which any person signing below or an family Y member of the deceased wishes to preserve. (crematory name;. Pine Viev�Crematory is not responsible for removal of personal items from the container or from the remains of the deceased. Persona! items left in the container or with the remains will be destroyed by the cremation process and cannot be retrieved after cremation. k INVe hereby authorize (crematory name) Pine View Crematory; to cremate the emains of the deceased. FINAL DISPOSITION The person authorized to receive the cremated remains of the deceased from the crematory is: Name; Carleton Funeral Home,Inc. Address: 68 Main Street, Hudson Falls,NY 12839 Phone: 518-747-4243 The cremated remains of deceased will be disposed of as )Ilows: If for any reason the person named above does not take possession of the cre4ted remains, (crematory name) Pine View Crematory is authorized to give possession of the remains to (funeral home name) Carleton Funeral Home,Inc, by delivery in person or by registered mail, Le_i S- r✓)a,� �f DOS-1898-f-1(Rev.01110) Name of r)P.rHACP.rf Paoe 2 of 3 ) following)lie Me understand that if the remains are not claimed {ivithin 120 days of cremal (crematory name) Pine View Crematorium io n, such as by scattering. _;_may dispose of the re wins in an irretrievable manner, CREMATION CONTAINERIURN (initial ONE of the following) An urn to be used as a container for the cremated r:.maih as been purcha ed from Carleton Funeral Home,Inc.. and is descri'red as follows: IIWe understand that if the urn is too small to hold the entire :;ev�� used for delivery, mated remains, an ad itional rigid container may be -OR- NW W An urn has not yet been purchased. INUe understai-ld that if no urn is purche sed or.otherwise provided Premcosta ory inert r �,dU � will place the cremated i remains in a rigid temporary container for delivery. - The Authorization Form was provided by (funeral director name) _ 1 / was executed at (funeral home name) Carleton Funeral Home, Inc. (funeral home address) 68 Main Street, Hudson Falls N`� 12839 and is signed by the funeral director as witness to its execution, I/We have received a completed copy of this Authorization Fc rm. The person(s) identified below is/are the person(s) in cot itrol of disposition, who by signing this Authorization Form, attest(s) to the accuracy and complE teness of the informati n contained in this Authorization Form and authorize(s) the foregoing. Signed this day of Typed or Printed Name A z Qtu 90 S97 Address Typed or Printed Name Signature Address - Typed or Printed Name Signature Address WIT SS; c� t 1,4 Ul Funeral Director Typed or Printed Name Funeral t for Sila—cj 0 q 9k Registration Number I i DOS-1898-f-I(Rev.01/10) Name of Deceased Page 3 of 3