Smith, Barbara Pille View Cellietery & CrerriaLorluill
Quaker Road
Queensbury, NY 12804
(.518) 745-4477 or (518) 74.5-4476
Funeral Home __-- rtw rcOwpof
Requested Return 'I'll lie__________
Na111C----------- r �� -- -----------------Case NO. -----------
Date of Creination �12h�i "l'inlc Startc(l 4_ Time COI111)ICIC(l m
Placed in Hold:
Placed in in Refrigeration:
Placed in Retort: $_'If
Type of Container___----__£° "c�---�v_Kc�-- °----,�rr �__<w �•r^_
----------------------=. 1-6-0 ------------------------------------------------
Remarks
Main ----------------------------------------- Move-------------!D
Place of Dcadi___--
Estimated Weight.of'Remains and Container_____________ 2" ( j� �---- ------� r------
Dale&Time, Remains arrived at.Crematory------------------!I IA------7,1WL ----
Name of Funeral Director or Registered Resident Delivering Remains__—_JL,, H��,;mW__
I
Detailed reason for delay II remains were cremated more thaI1 48 hours from time of accepted
delivery
---------------------------------------
---------------------------------------------------------------------------
Retort Number in which Remains were cremated---------------T-O�---�--------------
Note:The Creination I,og shall be retuned in the Permanent Filc of tlic Crematory j
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:JULY 20,2019 Number:2019-026
Crematory Name:PINE VIEW CREMATORIUM
Address: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 um. Cremated remains generally are pulverized until no single fragment is
recognizable as skeletal tissue.
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.
IDENTIFICATION OF DECEASED
Name of Deceased:BARBARA J. SMITH Marital Status:WIDOWED
Last Known Address:36 TRAVIS LANE BRANT LAKE,NY 12815
Place of Death:36 TRAVIS LANE BRANT LAKE,NY 12815
Sex: ❑M OF Age:82 DOB:12/03/1936 Date of Death:07/20/2019 Estimated Weight:240 I-tJJTJr
Description of casket/container in which remains will be delivered:
FLORENCE CASKET COMPANY/CREMATION CONTAINER/FIBERBOARD
PERSON IN CONTROL OF DISPOSITION
(Person(s)in control of disposition, in"i 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 Law section 4201.
I/We have no knowledge that the deceased executed a written instrument pursuant to Public Health Law
s on 4201 or a will containing directions for the disposition of his or her remains and (Continued next page)
cti
BARBARA J.SMITH
DOS-1898-f-I (Rev.01110)
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:5 Description:CHILD/DAUGHTER
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 dose 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).
(Ini i I ALL THREE of the following)
I/We hereby affirm that the body of the deceased does not contain a battery, battery pack, power cell,
ra oactive 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/We hereby affirm that instructions have been given to (funeral directorname)JAMES P. McDERMOTT
c T
+rearding 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. (crematory name)PINE VIEW CREMATORIUM is not
responsible for removal of personal items from the container or from the remains of the deceased. Personal items
ft in the container or with the remains will be destroyed by the cremation process and cannot be retrieved
ter crem
ation.
I/We hereby authorize(crematory name)
PINE VIEW CREMATORIUM to cremate the
re ains of the deceased.
FINAL DISPOSITION
The person authorized to receive the cremated remains of the deceased from the crematory is:
Name:JAMES P. McDERMOTT/OR EMPLOYEE
Address:9 PINE ST CHESTERTOWN,NY 12817 Phone:518-494-2811
The cremated remains of deceased will be disposed of as follows:
INTER AT BRANT LAKE CEMETERY BRANT LAKE,NY
If for any reason the person named above does not take possession of the cremated remains,
(crematory name)PINE VIEW CREMATORIUM is authorized to give possession of the remains to
(funeral home name)BARTON-McDERMOTT FUNERAL HOME,INC. by delivery in person or by registered mail.
BARBARA J. SMITH
DOS-1898-f-I (Rev.01/10)
Name of Deceased Page 2 of 3
•Initial the following)
UWe understand that if the remains are not claimed within 120 days of cremation,
(cr oratory name)PINE VIEW CREMATORIUM may dispose of the remains in an irretrievable manner,
such as by scattering.
CREMATION CONTAINERIURN
(1 i i 1 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:
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.
An urn has not yet been purchased. I/We understand that if no um is purchased or otherwise provided
(cre atoryname) PINE VIEW CREMATORIUM will place the cremated remains in a rigid temporary
container for delivery.
This Authorization Form was provided by (funeraidirecrorname)JAMES P. McDERMOTT
was executed at(funeral home name)BARTON-MCDERMOTT FUNERAL HOME,INC.
(funeral home address)9 PINE ST. CHESTERTOWN,NY 12817 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 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.
Si ed this 21TH day of JULY , 20 1ro I I e 9
c G of
Typed or Rinted Name u Signa e
fie 6ro"i
Address
Typed or Printed Name Signature
Address
Typed or Printed Name Signature
Address
WITNESS:
JAMES P. McDERMOTT
Funeral Director Typed or Printed Name uneral Dir6cll
Signat,6re
12330
Registration Number
BARBARA J. SMITH
DOS-1898-f-I (Rev. 01/10) Name of Deceased Page 3 of 3
AT-NEED WRITTEN STATEMENT OF PERSON
HAVING THE RIGHT TO CONTROL DISPOSITION
(Provided to Funeral Director)
PERSON OTHER THAN AGENT
, hereby represent and assert that I am entitled
Na of Next-of-Kin,Othe erson(Printed)
to control the disposition of the remains of 116a du'lzl ! j I further
Name of Decedent(Printed)
represent that I am the person having priority to control the disposition in accordance with Subdivision 2
of Section 4201 of the NYS Public Health Law. The order of priority set forth in Subdivision 2 of
Section 4201 of the NYS Public Health Law is the following:
■ Person designated in written instrument;
■ Spouse;
• Domestic Partner;
■ Any Child 18 or Older;
■ Either Parent;
■ Any Brother or Sister 18 or Older;
■ Authorized Guardian;
■ Person 18 or Older now Eligible to Receive an Estate Distribution, in the following order:
*Grandchildren;
*Great-Grandchildren;
*Nieces and Nephews;
*Grand-nieces and Grand-nephews;
*Grandparents;
*Aunts and Uncles;
*First Cousins;
*Great-Grandchildren of Grandparents;
*Second Cousins;
■ Fiduciary;
■ Close friend or other relative who is reasonably familiar with the decedent's wishes, including his
or her religious or moral beliefs, when no one higher on the list is available, willing, or competent
to act; (NOTE: This person must complete an "At-Need Written Statement of Person Having the
Right to Control Disposition" form.)
■ Public administrator(or the same official in a county not having a public administrator); or, anyone
willing to act on behalf of the decedent who completes the"At-Need Written Statement" form.
I also have no knowledge that the decedent executed a will containing directions for the disposition of
his/her remains,or designated an agent by executing a written instrument pursuant to Section 4201 of the
Public Health Law.
Date: � u� � 1
+reof"Person �therhan Agent"
Original—Funeral Director Copy—Next-of-Kin