Ross, Barbara Pine View Cemetery & Crematorium
(quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
Funeral Hotiie
Requested Return "Time
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Name------—�'—`►��gtiL--- -------------------Case No ----------
7iiz►l5 �S�-------
Date of Cremation 3WK114. '(uric Sl<lrled__ Time Coml)letc(1__ �_�q S
Placed in Hold: --------IL j j Ah___
Placed in Refrigeration:
Placed in Retort ----JZ_1 Tt7 __
1`yPe of Container — t�-� "
� ��4---------------------
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Remarks
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Main ----------------------------------------- Move----------
Place of Deatl i--------- ��----- ��k�-----c t kt---���"► -- --
Estimated Weight of Remains and Container-------_____J
Date&Time Remains arrived at Crematory----------------`7f 10______—
Name of Funeral Director or Registered Resident Delivering Remains.......Zoo\
Detailed reason for delay if remains were cremated more than 48 hours from time of accepted
delivery
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Retort Number in which Remains were cremiate(1 $Rk-T ____
Note:The Cremation Log sliall be retained in the Permanent File of llic Crematory
New York State
NEW YORK D�V�S�OR �f Department of State
STATE OF DIVISION OF CEMETERIES
OPPORTUNITY. Cemeteries One Commerce Plaza
99 Washington Avenue
Albany,NY 12 2 31-0 0 01
Telephone:(518)474-6226
Authorization for Cremation and Disposition www.dos.ny.gov
This Authorization Form must be completed and signed prior to delivery of remains for cremation.
Date: 07/11/2019 �S
Number:
crematory Name: Pine View Crematory
Address: 21 Quaker Rd., 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: Barbara C. Ross Marital Status: Married
Last Known Address: 175 Antler Lake Rd., PO Box 26, Wevertown, NY 12886
Place of Death: Albany Medical Center Hospital, , Albany, NY 1-11W
Sex: ®M ® F Age: 80 DOB: 01/31/1939 Date of Death: 07/10/2019 Estimated Weight: 155
Description of casket/container in which remains will be delivered.
Florence Minimum corrugated
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 L w Section 4201.
-OR- >�
IMe 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:
Barbara C. Ross
(Name of Deceased)
DOS-1SW(Rev.08115) Page 1 of 3
Authorization for Cremation and Disposition
(/nett from the list below)
Number: 2 Description:S Ouse
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;
s• 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
w Section 4201(7).
( A L 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,
or radioactive device and that any such materials were removed prior to the execution of this Authorization Form. Failure to remove
the a prior to cremation may result in harm to the crematory and crematory personnel.
I/We affirm that instructions have been given to John S. Alexander
(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 Crematory
is not responsible for the removal of personal items from the container or f om the remains of the deceased. Personal items left in the
con i r r with the remains will be destroyed by the cremation process and cannot be retrieved after cremation.
tI e hereby authorize Pine View Cremator
(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:
Name:Alexander-Baker Funeral Home, John S. Alexander
Address: 3809 Main Street, Warrensburg, NY 12885 Phone: (518) 623-2065
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 Crematory is authorized to give possession of
(Crematory Name)
the remains to Alexander-Baker Funeral Home by delivery
(Funeral Home Na—)
in person or by registered mail.
Barbara C. Ross
(Name of Deceased)
DOS-1898-f(Rev. 08115) Page 2 of 3
Authorization for Cremation and Disposition
(ln i tlti)'fol%wing)
`� I/We understand that if the remains are not claimed within 120 days of cremation,
Pine View Crematory
an irretrievable manner, such as by scattering. (Name or crematory) may dispose of the remains in
CREMATION CONTAINER/URN
(initial ONE of the following)
An urn to be used as a container for the cremated remains has been purchased from Alexander-Baker Funeral
and is described as follows:
INVe understand that if the urn is too small to hold the entire cremated remains, an additional rigid container may be used for delivery.
An urn is not yet purchased. I/We understand that if no urn is purchased or otherwise provided
Pine View Crematory
(Nameofcrematory) will place the cremated remains in
a rigid temporary container for delivery.
This Authorization Form was provided by John S. Alexander
(Funeral Director Name) was executed at
Alexander-Baker Funeral Home
ome Namp)
3809 Main Street,H
Warrensburg, NY 12885
(Funeral Home Address)
and is signed by the funeral director as witness to its execution.
INVe 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 rization Form and authorize(s)the foregoing.
Signed this 11th day of July 20 19
Philip Ross �
Typed or Printed Name Signs
PO Box 26, Wevertown, NY 12886-
Address
Typed or Printed Name Signature
Adtlress
Typed or Punted Name Signature
Address
WTNESS:
John S. Alexander
(Funeral D,.aar Typed or PKrted Name) uner or Signature)
10036
(Rog )
Barbara C. Ross
(Name ofDeceased)
14 CX Page 3 of 3