Hinton, Annamarie Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
Funeral Hoene
+' Requested Return"1'inle_---____-_
Naive-------Akn_NtL----Mo�q�_ _±l Mho -------Case No. -------y3 b ---------
Date of Cremation---71)s 11a "rime Startcd...I_3�figrinic Completed_ I0: l
Placed in Hold:
Placed in in Refrigeration:
Placed in Retort: op1n
Type of Container------------�t�l�lq ---CK*01 a.--+ =- N"
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Remarks
---------------------
Main ----------------------------------------- Move------------ 0
Place of Death--------A&i, ----------------------------------
Estimated Weight of Reiiiains and Container------------ -I�_s_-�,0 --------------------
Date&Time Remains arrived at Crematory-_.________________ I_ 7IIzJl�i___Z_»PF1__
Name of Funeral Director or Registered Resident Delivering Remains-------MAIL C _k c_
Detailed reason for delay if remains were cremated more dean 48 hours From time of accepted
delivery
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Retort Number in which Remains were cremated WyL f'TA V-z_______________
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Note:The Cremation Log sliall be retained in the Permanent File of dic Crematory
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NYS Department of State
Authorization for Cremation and Disposition 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: -7(11,1 LS -
Number:
Crematory Name: Pine View Crematorium
Address: Quaker Road, Queensbury,NY 12804 Phone:
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. I
OPENING OF 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 crematory property. If human remains are delivered in a container which is not suitable for cremation
such as a 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.
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IDENTIFICATION QF DECEASED
tiff 04PWrm
Name of Deceased: Abja all, Marital Status:
()(�A'Marl t
Last Known Address: 9s z Z44„c 05�r-- /9
Place of Death: Al a
Estimated Weight:
�/ s
Sex: M ® Age: �_ DOB: ��8/��g Date of Death: _ 9
Description of casket/container in which remains will be delivered: j
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PERSON IN CONTROL OF DISPOSITION
p(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
p Public Health Law section 4201.
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hl/W have no knowledge that the deceased executed a written instrument pursuant to Public Health Law
ion 420 or a will containing directions for the disposition of his or her remains and (Continued next page)
_ &�E /If l�,bvr
DOS-18984-1(Rev.01/10) Name of Deceased Page 1
i(Initial t�foil wing)
I e understand that if the remains are not claimed within di 0 daydisp of cremation,
ose the remains in an irretrievable manner,
name) Pine View Crematorium y p
such as by scattering.
CREMATION CONTAINER/URN
(Initial ONE of the following)
An urn to be used as a container for the cremated remains has been purchased from
Carleton Funeral Home, Inc.. and is described as follows:
Pfor
d that if the urn is too small to hold the entire cremated remains, an additional rigid container may be
lry.
n has not yet been purchased. Me understand that if no urn is purchased or otherwise provideP1 ru
uwill place the cremated remains in a rigid temporary
elivery.
<<ts�
The Authorization Form was provided by (funeral director name) n�►L P
WaS executed at (funeral home name)
Carleton Funeral Home, Inc.
(funeral home address) 68 Main Street, Hudson Falls,NY 12839 and is signed by the funeral director
as witness to its execution.
Me 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
Authorization Form and authorize(s) the foregoing.
9 9.
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Signed this lb day of (" 20 -LL.
ituts
Typed or Printed me
Address
Signature
Typed or Printed Name
Address
Typed or Printed Name
Signature
Address
WITNESS:
AA
clts<
re neral Director ignature
Funerall Director Typed or Panted Name
`7.Z�/� .
//►► �✓( ai
Registration Number {-r-
�h n 0.rr-IcL ri e v
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DOS-1898-f-1(Rev. 01/10) Name of Deceased Page 3
I Qm/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: Y Description: Maw
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§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
nt to Public Health Law §4201(7)
:)implant,
REE of the following)
hereby affirm that the body of the deceased does not contain a battery, battery pack, power cell,
or radioactive device and that any such materials were removed prior to the execution of this
uthoriz on Form. Failure to remove these items prior to cremation may result in harm to the crematory and
Z
:22
tory ersonnel.
hereby affirm that instructions have been given to (funeraldirectorname)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. (crematory name) Pine View Crematorium is not
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Dthe
for removal of personal items from the container or from the remains of the deceased. Personal items
ontainer or with the remains will be destroyed by the cremation process and cannot be retrieved
tion.
e hereby authorize (crematory name) Pine View Crematorium to cremate the
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 follows:
��-
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) Carleton Funeral Home, Inc. by delivery in person or by registered mail.
DOS-1898-f-I(Rev.01/10) Name of Deceased Page 2 of 3
c to Bret�cc ty1 e /�),gcll1°