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Evans, Edward Pine View Cemetery & Crematorium Quaker Road Queensbury, NY 12804 (.518) 745-4477 or (518) 745-4476 Funeral Home __-- Requested Return l'iule___t�EQN"'J - 'eI t� �`='S--------------------Case No ------- � _ J Name____--� r Date of Cremation---'71 bJl5__--rinic Started_ Time Coniplctcd_____-- - Placed in Hold: 1_ir _____ Placed in Refrigeration: Placed in Retort: "Type of Container------ �,,�--—�'1-` -- ----- � �ti"Q!�'K -- ,aAt!�Kl- ---------- Remarks --------------------- Mai►1 ----------------------------------------- Move----------- $:WtII $4m 1:70 Place of Death-------- g� --- �� ---- ---jib---------------------- Estimated Weight of Remains and Container------------(gb--- 4-f Date&Time Remains arrived at Crematory------------------ �I l�Il i______I 7t fh____-_ Name of Funeral Director or Registered Resident Delivering Remains______ ;�iQ____ Detailed reason for delay if remains were cremated more than 4.8 hours from time of accepted delivery ---------------------------------------------------------------------------- --------------------------------------------------------------------------- Retort Number in which Remains were cremated S (t__ ig ---AIC__-___--- Note:The Cremation Log shall be relalincd in the Permanent File of tlic Crematory Ws Nparw*m of Stabs Aothofization for Cremation and Disposition o� pia AVWW WW A bang,My 12231 (518)474-6226 www.dos.tate.ny.us This Aethorizadbn Form must be comP16ftd and signed Per to eery of remains for cremation Date: Number. Q Name: l � Crematory _ Address: AJ Phone: y7 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. at Following cremation,the crematory will take reasonable efforts to remove all of the remains and other i tpfrom the cremation chamber,but some ate minimal dust and residue will likely be left behind.The crematory of as incidental and foreign material from the remains and the Incidental and foreign material will be disposed a required by law.The cremated remains will be mechanically pulverized into small pieces and placed' designated container or um. Cremated remains generally are Pulverized unt11 no single fragment is recognizable as skeletal tissue. OPENI it 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 nto a suitable such as a ceremonial or rental casket,t The a container �t mainssfer r r�etrto�valeodf i mains will be container before it accepts the remains. opening conducted before a witness and will be done in privacy,with dignity and respect. IDENTiFI AT10N OF DECEASED Marital Status: Name of Deceased: 1/ L/ Last Known Address: 1 a O ZO Place of Death: �' Sex: QM OF Age:RJ DOB: ate of Death: iE3 Estimated Weight Description of casketicontainer in which remains will be delivered: 4 PERS 'IN CONTROL OF QISPO_�CIl4� (person(s)in control of disposition, 'r�ti l ONE of the following) I aml 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 decea =on uted a written instrument pursuant to Public Health Law directions for the dis of his or her remains and (Continued next Pam) section 4201 or a will containing di �� A�� /� A page 1 of 3 Name of Decomd DOS-1888 N (Rev.01110) 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 foilows: (Insert from the list below) Number:__ Description: 4J � 1.A person designated in writing pursuant to Public Health.Um 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; T.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 pursuant to Public Health Law§4201(7). (Initial ALL THREE of the following) �z— I/We hereby affirm that the body of the deceased does not contain a battery, battery pack, power cell, ra_dioactive implant, or radioactive device and that any such 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. I _ I/We hereby affirm that instructions have been given to munenwdvwtorneme) � re6arding the removal of any personal property or other thing alue which any persqp signing below or Z family member of the deceased wishes to preserve. (aematory name) /ChFt,r�cJ 0- &1"110 h�I Ls- 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(awnstay mme) ������� f��A- �(IL to cremate the re airs of the deceased. FINAL DISPOSITION •" The person au orized to 4recap the cremated remains of the deceased from the crematory is: Name: 14 Address: A r� Phone:( The remated remains of deceased will be disposed of as follows:Ic .1-1 AIWA-A Al �-,-o �t q,09� If for any reason a person named abo a does not take possession of the cremated remains, (amatory name) d/EJ 17 Qt tl is authorized to give possession of the remains to (funeral tome none) by delivery in person or by registered mail. DOS-18WN (Rev.01110) Name of Dwwsed Page 2 of 3 (Itrltist the following) -T NVe mqderstand that if the mains are not clai within 120 days of cremation, (aemeroryneme) ct� �(' ft'J�9-�75 may dispose of the remains in an irretrievable manner, such as by scattering. CREMATION CONTAINER/URN (jam ONE of the following) An um to be used as a container for the cremated remains has been purchased from and is described as follows: UWe understand that if the um is too small to hold the entire cremated remains,an additional rigid container may be used for delivery. -OR- "T'"— An u s not yet been pu ased. IM/e understand that if no um is purchased or otherwise provided ( royname) e Lgc will place the cremated remains in a rigid temporary container for delivery. This Authorization Form was provid y(funewdmcwname) �- was executed at(funerai home name) ` (funeral home addraso r9- 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 istare the person(s)in control of disposition,who by signing this Authorization Fonn,attests)to the accuracy and completeness of the Information contained in this Authorization Fonn and authorize(s)the foregoing. e--- Q Signed this /i5 day of �� 20.L L_• Typed or Printed Name Signature 4.266( Addrdss Typed or Printed Name Signature Address Typed or Printed Name Signature Address WITN SS: /WU Funeral 01kow Typed or Printed Name AIE-2y Registration Nu OCM-1tl9844 (Rev.01H0) Name of Deceased Page 3 of 3