Kelley, Lois Pine VICW Cemetery & O'ClUiLLOriurll
Quaker Itoad
Quc:,ensbury, NY 12804
(518) 745-4477 or (518) 7C)-4476
[�uneral 1-IOl11C
Requeme'd Return Time__A n-e
Name
Dace of Crelllation___9`1 --- I'inlc Startc(I /Z ", _I'inlc Completed. �Q
Placed in Hold: 7
Placed In in Refrigeration: -
Placed in Retort:
"t'yl)c of
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Remarks
Main
------� Move Z 3-!5 .
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Place of Dcatl l(� ►d�?4,1Lr_✓�`�-� 4
J- -1-----------
Estimat.ed Weight.of Remains �11
1
(1 Collt�""'-____,1
Dale&Time Remains arrived at Crculalory_ 1-------------------------------------------
Name of Funeral Director or Registered Resident. Delivering Remains-L—k�w �IT►p,,,.
----
Ddailed reason Io,- (lelay If I-elllaills were cremated 111O1•C (han 48 hours From tlrlle Of accepted
delivery
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Retort Number in which Remains were crcnlated 51" -__----
Note:'I'lle Cl-ellIatioll I,og Sllali hC rClaincd in the PCr UMICnt File ol'llle Crcruatory
Authorization for Cremation and Dispositica NYS Department of state
z l7 Division of Cemeteries
One Commerce Plaza,99 Washington Avenue
Albany,NY 12231
(518)474-6226
.i . wwwAos,state.ny.us
This Authorization Form must be completed and sr"rlhed prior to delivery of remains for cremation.
I
Date: Number: S
Crematory Name: Pine View Crematoriiun
Address: Qualcer Road, Queensbury,NY 12804 Phone: -1'/!, 7&/5- 4/c/ 7
CREMATION IS AN IRREVERSIBLE AND FINAL PROCE&'
Cremation is carried out by placing the remains of the deceGud and the container holding the remains.into a
cremation chamber where they are subjected to intense heal: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 effort'sto remove all of the re�nains.and other material from
the cremation chamber, but some minimal dust and residue��i;ill 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 I pulverized into small pieces and placed into a
designated container or urn; Cremated remains generally ae:e pulverized until no single fragment is
recognizable as skeletal tissue.
OPENING OF CONTAINER.
The crematory may only open the container holding the un-cr-c mated 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 deliveryOn a container which is not suitable for cremation
such as a ceremonial or rental casket, the crematory will r6quire that the remains be moved into a suitable
container before it accepts the remains. The opening of a container or the transfer oIr removal of remains will be
conducted before a witness and will be done in privacy, with rignity and respect.
IDENTIFICATION OF DECEASED
Name of Deceased: f i• [ ME�:
arital Status: y(/
Last Known Address: _ �c ,,, S
Place of Death: G I ev,S i f N ►�� j ('/
Sex: M Age: 3 DOB: t`E9 Dat, of Death: t Estimated Weight: fWA
Description of casket/container in which remains will be delive;ed:
J
PERSON IN CONTROL OF DISPOSITION
(Person(s) in control of disposition, Initial ONE of the following)
VK "S 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-
INVe have no knowledge that the deceased execute) 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)
k-C
DOS-1898-f-I(Rev.01/10) Name of Deceased Page 1 of 3
I am/we are the person(s) having priority under Public Heat t Law section 4201 and have the right to authorize
cremation of the remains-of the deceased. MylOur relati:r'nship to the deceased is as follows:
(Insert from the list below)
Number: Description:
� .6
1. A person designated in writing pursuant to Public f-I �' Ith 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 end 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 F�ublic Health Law§4201(7);
10.A chief fiscal officer of a county or a public administrator appointed pursuant to the Surrogate's Court
Procedure Act;
1 Oa.Any other person who is acting on behalf of the c'6ceased 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,
radioactive implant, or radioactive device and that any sure,materials were removed prior to the execution of this
Authorization Form. Failure to remove these items prier to cremation may result in harm to the crematory and
crematory personnel. /0
kS INVe hereby affirm that instructions have been gi,;bn to(funeral director name) �L
regarding the removal of any personal property or other thing of value which any pef son signing below or any family
member of the deceased wishes to preserve. (crematory name,j Pine VieW Crematory is not
responsible for removal of personal items from the contairn:!� 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.
k5 Me hereby authorize (crematoryname) Pine View Crematory, to cremate the
remains of the deceased.
FINAL DISPOSITION
The person authorized to receive the cremated remains of the deceased from the cr matory 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.f')'I llows:
rV, S�n,4, - da-6 vou
+7-0VV4-1)lv� Ce-vt-i Y
If for any reason the person named above oes not take p,)ssession of the cremate re ains,
(crematoryname) 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.
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DOS-1898-f-I(Rev.MAO) Alamo of r)P.nP.ARP.d Psae 2 of 3
�Llnitiql.the following)
5- _ INVe understand that if the remains are not claimE)d !Nithin 120 days of crema�
(crematory name) Pine View Crematorium �ion,
such as by scattering. __,_may dispose of the re 'ains in an irretrievable manner,
CREMATION CONTAINER/URN
(initial ONE of the following)
An urn to be used as a container for the cremated iiamairi1i5as been purcha
Carleton Funeral Home, Inc., and is descri tied as follows; sed from
INVe understand that if the urn is too small to hold the entin, -remated remains, an ad itional rigid container may be
used for delivery.
Nd�- An urn has not yet been purchased. INVe understand that if no urn is purche sed or otherwise provided
(cremaforyname) ;IIItJ;!, ) , will place the cremated remains in a rigid temporary
container for delivery. . -The Authorization Form was provided by (funeral director name)
was executed.at (funeral home name) -r e C `
Carleton Funeral Home, Iiic. '
(funeral home address) 68 Main Street, Hudson Falls 11`` 12839 '
and is signed by the funeral director
as witness to its execution.
INVe have received a completed copy of this Authorization 1- rm.
The person(s) identified below is/are the person(s) in corltrol of disposition, wh' by signing this
Authorization Form, attest(s) to the accuracy and compkieness of the information contained in this
Authorization Form and authorize(s) the foregoing.
Signed t is �' day of 201
Typed or Printed Name
51 nature
16 C-fL �I � 1Z�m� ✓)Y � I
Address -
Typed or Printed Name Signature
Address --
Typed or Printed Name Signature I
Address --
W ESS:
V "( c �►
Funeral Director Typed or Print d Name - Funeral , ector Signature
ld Q ��
Registration Number
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DOS-1898-f-I(Rev.01/10) i