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Bray, Marlyn Pine VICVV Cenle ery `d( Crelrlat(�riuln Quaker Road Queensbury, NY 12804, (518) 74,5-4.477 or (,518) 74,5-4476 Funeral k-Iolllc Re<lueste(l Retul-11 'I'll Ile Name --------- 4P'I`�1--- _.._Case No. Date of Cremation----_qA LIj__'1'inle Startccl 1_01_-Tillie Conlf�ie(e(l.__ 3; 00 Placed in I-Iol(I: Placed in Reli-igeration: i Placed in Retort: --_-_ "u_ Type of Cont<uncr Remarks ---------------------- Main Move -------------------------- - --- -------- PlaceoCDcatlr [slimated Weight.of Remains and Collulincr------_-_��-_J�. _------_---- Date&'Time Remains arrive(1 a(.Crematory-_-- p j Name of Funer�ll Director or Registcral Resident Delivering- Remaltis IC�CaE Detailed reason Io,- delay il'reluains were cremated more (Ilan 48 hours from Mlle of accepted delivery --------------- ----------- ----------------------------------- i --------------------------------------------- - Re(.ort Number in which Remains were cremated Notc:'I'llc Cre elation I,og shall be retained in the 1'cr111a11cut File of(.he Crcmalory i Authorization for Cremation and Dispositionar One Commerce Plaza, a ing on venue Albany,NY 12231 (518)474-6226 wwwAos.ny.us This Authorization Form must be completed and signed prior to delivery of remains for cremation. Date: 1110 115 Number: LOL Crematory Name: Pine View Crematory Address: Quaker Road, Queensbury, New York 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 heatandflame.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 an 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 um. Cremated remains generally are pulverized until no single f1rnt is recognizable as skeletal tissue. OPENING OF CONTAINER The crematory may only open the container h ` ``,fie un-cremated human remains in limited circumstances, such as to confirm the identity of the deceased or to ensure' t no material is enclosed which might injure employees or damage crematory property. If human remains are de d In a container which is not suitable for cremation such as a ceremonial or rental casket, the crematory °require that the remains be moved into a suitable container before it accepts the remains.The opening of a cony or the transfer or removal of remains will be conducted before a witness and will be done in privacy, with dignity and resp . IDENTIFICATION OF DECEASED Name of Deceased: M A({L`(f ) -3u qC-c� A P.A�! _ Marital Status: M/I JC R( L''() Last Known Address: JS -rW" / CWC)o0 L NC /y✓ 1 2 &-q Place of Death: DOB: Date of Death: � 2-CJ( Estimated Weight: Sex: ❑M OF Age: g� Description of casket/container in which remains will be delivered: Corrugated Cardboard Box with Plywood Starmark Model#38808 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 th Law section 4201. -OR- 19�—' 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 (Continued nextpage) g&T & DOS-1898-f-I (Rev. 12/11) Name of Deceased Page 1 of 3 I am/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: (Insert from the list below) Number: :3 Description: -50N 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§4201(7); 10. A chief fiscal officer of a county or a public administrator appointed pursuant to the Surrogate's Court Procedure Act; 1Oa.Any other person who is acting on b6,bj ._of the deceased and who has executed a written statement pursuant to Public Health Law§42010 Initial ALL THREE of the following) I/We hereby affirm that the body off deceased does not contain a battery, battery pack, power cell, Moactive implant, or radioactive device and t any such materials were removed prior to the execution of this Authorization Form. Failure to remove these ios prior to cremation may result in harm to the crematory and crematory personnel. t C—) INVe hereby affirm that instructions have been given to (funeral director name) Starr Baker #10159 regarding .al of any personal property or other thing of value which any person signing below or any family member of the deceased wishes to preserve. (crematory name) Pine View Crematory is not responsible for 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 (crematory name) 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 crematory is: Name: Baker Funeral Home Personnel Address: 11 Lafayette Street Queensbury New York 12804 Phone: (518)761-9303 The cremated remains of deceased will be disposed of as follows: Return to family to be decided If for any reason the person named above does not take possession of the cremated remains, (crematory name) Pine View Crematory is authorized to give possession of the remains to (funeral home name) Baker Funeral Home by delivery in person or by registered mail. 6AYjv , ,i DOS-18984-J(Rev.01/10) Name of Deceased Paoe 2 of 3 Initial the following) I/We understand that if the remains are not claimed within 120 days of cremation, Jstory name) Pine View Crematory may dispose of the remains in an irretrievable manner, such as by scattering. CREMATION CONTAINER/URN /nitial ONE of the following) An urn to be used as a container for the cremated remains has been purchased from Baker Funeral Home and is described as follows: 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. -O - An urn has not yet been purchased. I/We understand that if no um is purchased or otherwise provided (crematowname) Pine View Crematory will place the cremated remains in a rigid temporary container for delivery. This Authorization Form was provided by mxjo name) 7 l aEn c i �b2j2 was executed at(funeral home name) Baker Funeral Home (funeral home address) 11 Lafa ette Street New York 12804 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 (s)in control of disposition,who by signing this Authorization Form, attest(s)to the accuracy and completboists of the information contained in this Authorization Form and authorize(s) the foregoing. Signed this day of�� ,20 . Typed or Printed Name 6zY Abrice< Pe yr PD VA S /viC o4ogfo Address Typed or Printed Name Signature Address Typed or Printed Name Signature Address WITNESS: Funehi6irectbPT ed o anted ame F n hector gnat Funeral Home Reg.#01130 Registration Number A.Y ,`o ,ona s_i im—, o aim Name of Deceased Paoe 3 of 3