The URL can be used to link to this page

Olsen, Robert Mlle View Cemetery & Crenlat.onu111 QuakeI' Road Queensbury, NY 12804 (.518) 745-4477 or (518) 745-4476 Funeral Home I Requested Return 'l'1me____AAP - Naule-------- � -�--- --------------------Case No. ----------13 Date of Cremation__-)InIll 'rimc Startcd__ 1_7oQ� "1-111C Coniplctcd I-°TL_ Placed in Hold: Placed in Refrigeration: Placed in Retort: Type of ConGllncr------�1N��b__t 45(� 1------1ofr✓�i� -_��lV��i__._------------ -------------------------------------------------- I I Remarks --------------------- Main ----------------------------------------- Move------------- Place of Death-------------- j Estiniated Weight of Remains and Container )4 __________ 0 � ---- s...................... Date &Time Remains arrived at Cremator � M y-------------7111 I Iy-----fl '1 �'-1---- - ----------- Name of Funeral Director or Registered Resident Delivering Remains.....aesa vv' Stlf i.� Detailed reason fin• delay if remains were cremated more than 48 hours from tulle of accepted delivery -------------------------- -------------------------------------- ---------------------------------------------------------- Retort Number in which Remains were crematedS .g — _--__—_ Note:'hie Cremation I,og shall be retained in talc Permanent File of the Crematory I I New York State Department of State _/'+ NEW YORK Division of DIVISION OF CEMETERIES STATE OF One Commerce Plaza OPPORTUNITY. Cemeteries 99 Washington Avenue Albany,NY 12231-0001 Telephone:(518)474-6226 www.dos.ny.gov Authorization for Cremation and Disposition This Authorization Form must be completed and signed prior to delivery of remains for cremation. Date: 07/16/2019 Number: 113 Crematory Name: Pine View Crematorium Address: 51 Quaker Road, 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: Robert Olsen Marital status: Married Last Known Address: 60 Waller Road, Gansevoort, NY 12831 Place of Death: Home Of The Good Shepard, 60 Waller Road, Gansevoort, NY 12831 Sex: ®M OF Age: 87 DOB: 07/25/1931 Date of Death: 07/16/2019 Estimated W ght: Description of caskettcontainer in which remains will be delivered. Corrugated cardboard C"�t 1 I 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 It aw on 4201. -O - �'INVe ve no knowledge that the deceased executed a written instrument pursuant to Public Health Law Section 4201 or a will containing dir coons for the disposition of his or her remains and Itwe are the person(s)having priority under Public Health Law Section 4201 a have the right to authorize cremation of the remains of the deceased. My/our relationship to the deceased is as follows: Robert Olsen (Name of Deceased) DOS-1898-f(Rev. 08/15) Page 1 of 3 i Authorization for Cremation and Disposition (Insert from the list below) Number: 2 Description:spouse 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 Section r r 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 gregarding n 4201(7). E of the following) hereby affirm that the body of the deceased does not contain a battery, battery pack, power cell, radioactive implant, ice and that any such materials were removed prior to the execution of this Authorization Form. Failure to remove r to cremation may result in harm to the crematory and crematory personnel. affirm that instructions have been given to Cassidy VonStettina (Funeral Dxector Name) oval 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 Crematorium (Cremetay Name) is of res risible for the removal of personal items from the container or from the remains of the deceased. Personal items left in the container or ith the remains will be destroyed by the cremation process and cannot be retrieved after cremation. IIW hereby authorize Pine View Crematorium (Crematory Nama) cre the remains of the deceased. FINAL DISPOSITION The person authorized to receive the cremated remains of the deceased from the crematory is: Name: Regan Denny Stafford Funeral Home, Cassidy VonStettina Address: 53 Quaker Road, Queensbury, NY 12804 Phone: (518) 792-1114 The cremated remains of deceased will be disposed of as follows: i Return to family If for any reason the person named above does not take possession of the cremated remains, it Pine View Crematorium is authorized to give possession of (Crematory Name) the remains to Regan Denny Stafford Funeral Home by delivery (Funeral Home Name) in person or by registered mail. Robert Olsen (Name of Deceased) DOS-1898-f(Rev. 08/15) Page 2 of 3 I i ' r Authorization for Cremation and Disposition Initial the followi qo J % IMe u erstand that if the remains are not claimed within 120 days of cremation, Pine View Crematorium may dispose of the remains in (Name o/Cremetory) an irretrieva manner, such as by scattering. CONTAINER/URN nitial ONE the following) Regan Denny Stafford ALI urn to be used as a container for the cremated remains has been purchased from and is de ibed as follows: Us SMWM'M Urn fi)r 1ALUAM44:uAN r ��; a, nderstand that if the urn is too small to hold the entire cremated remains, an additional rigid container may be use ford live , COt0VK rN.4 -OR- An urn is not yet purchased. Me understand that if no urn is purchased or otherwise provided Pine View Crematorium will place the cremated remains in (Name or Crematory) a rigid temporary container for delivery. This Authorization Form was provided by Cassidy VonStettina was executed at (Furm"I Dvector Name) Regan Denny Stafford Funeral Home (Funeral Home Name) 53 Quaker Road, Queensbury, NY 12804 (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 islare 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. Signed this 16th day of July Sally Olsen '6 Typed or Rioted Name nor 60 Waller Road, Gansevoort, NY 12831- Address Typed or Printed Name Sgnature Address Typed or Printed Name Signature Address WITNESS: Cassidy VonStettina (Furmal Di ecttor Typed or Pnnted Name) (Furwa vector Signature) M 09 (Registrabon Robert Olsen (Name o/Deceased) DOS-1898-f(Rev. 08/15) Page 3 of 3