Monahan, Edward Pine View Cemetery Lac, Crel—rlatol'1U111
(,quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 74.5-4476
Funeral Houle 8Xju
Requested Return Time-_ &W-_-
Name--------O ----MN,40---------------Case No --------10 ------
Date oC Cremation___ 7�7S� __"Cinlc Startccl__�_6S "1'111c Conlplctcd_____�Z-ua
Placed in Hold:
Placed in in Refrigeration: ----I" -_-
Placed in Retort: 10:05AM _
Type of Container _--� -------------
4(p-------------
------------ �otr+�,r --�a = --_-------------------------
Remarks
Main --------- Move--------
Place of Deatll6���r --�lIJ_-- I��A�
Estimated Weight of Remains and Container------- ------�1a Ar Z �
---------�----fig-=�-----
Date&Time Remains arrived at.Crematory------------------ 7LZr1�_____Q_i0;
Name of funeral Director or Regisl.cral Resident Delivering Remains----_PLOCE /r fod
Detailed reason for delay Ll remains were cremated more than 48 hours from time of accepted j
delivery
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Retort Number in which Remains were creniatcd---- Su _ s,,�F/�_-AC--------------
Note:rme Cremation Ag shall be retillncd in the Pcnnan nt file of llic Crematory
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, idelivery of remains for cremation.
Date: July 24, 2019 Number:
Crematory Name: L r V,1w CQlr it Td a 41
�t P
Address: 71 (vu ak' tea k PS�� ( V y0�hone: �p
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: Edward W. Monahan Marital Status: Married
Last Known Address: 64 West Starbuck Ln. , Fort Ann, NY. 12827
Place of Death: Glens Falls Hospital, 100 Park St. , Glens Falls, NY. 12801
Sex: EkM OF Age: 6 8 DOB: 0 7/14/61 Date of Death: 0 7/2 3/1 9 Estimated Weight: 110
Description of casket/container in which remains will be delivered. Florence Casket CO. Deluxe Tray
wood, wood composite base, cardboard top
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
Health Law Section 4201.
-OR-
0-4ft- I/We have no knowledge that the deceased executed a written instrument pursuant to Public Health Law Section 4201 or a
Will 0.nntaining directions for the.digp oSition 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:
Edward W. Monahan
(Name of Deceaseco
DOS-1898-f 08/15 Rev. Page 1 of 3
� ) 9
Authorization for Cremation and Disposition
(Insert from the list below)
Number:� Description: SPnw-C!,15
1. A person designated in writing pursuant to Public Health Law Section 4201(3);
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 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 Section 4201(7).
(Initial ALL THREE of the following)
aly-1—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
these items prior to cremation may result in harm to the crematory and crematory personnel.
I/We affirm that instructions have been given to Bruce K. Mason
(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. PT N 111fkd
(Crematory Name)
is not responsible for the 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 yw�( e
(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: Bruce K. Mason
'I
Address: PQ Rnx 277, Fnrt Ann, NY 12897 Phone: 518-639-5252 j
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,
PIS Evsf0 is authorized to give possession of
(Cram a ay Name I
the remains to Mason Funeral Home by delivery
(Funeral Home Name)
in person or by registered mail.
Edward W. Monahan
(Name of Deceased)
DOS-1898-f(Rev.08/15) Page 2 of 3
C
Authorization for Cremation and Disposition
(initial the following)
® I/We understand that if the remains are not claimed within 120 days of cremation,
cS gf a may dispose of the remains in
(Name of crematory)
an irretrievable manner,such as by scattering.
CREMATION CONTAINER/URN
(Initial ONE of the following)
&I—lix—An urn to be used as a container for the cremated remains has been purchased from Mason Funeral Home
and is described as follows: Solid Oak with engraved deer.
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.
-OR-
An urn is not yet purchased. I/We understand that if no urn is purchased or otherwise provided
�io'trtji - will place the cremated remains in
(Name of Crematory)
a rigid temporary container for delivery.
This Authorization Form was provided by Bruce K Mason was executed at
(Funeral Director Name)
Mason Funeral Home
(Funeral Home Name)
Fort Ann, NY. 12827
(Funeral Horne Address)
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.
Signed this j day of ZVI- ,20
pe Pnnted Name natur
64 West Starhuck Ln Fort Ann, NY 12897
Address
Typed or Printed Name Signature
Address
Typed or Printed Name Signature
Address
WITNESS:
(punorai rkrgrrnr Typed n annrnd Nemgl (Funaral Director Sionahrra)
<11 G
TRegTstration Number
Edward W. Monahan
(Name ofDeceaserq
DOS-1898-f(Rev.08/15) Page 3 of 3
Pine View Cemetery and Cre111atorluill
21 Quaker Road
QUeellsbury, NY 12804
.authorization to Separate Cremated Remains
Funeral Home M Oq
nircctor- u�[�_ ��o -------------------
DaLc
-s" rag No•------------------------
I/we au(liorire the SCI)airatiou of tIIC Cremated rcnlairlS oC 46�-toU/O#�w uIr ivoAl-41 "
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I/WC Illrtller agn-cc to hold harillless, in(Icrlliliry an(I (ICle11(1 the herein named creniatOrlUl11 as WCII
its their reps' ClltatWes, Il-oni and against all claims, hah11111CS ()I- (Ii1111i1hCS 4VllatSOC\'CI' Whieh may
I-CSlill lroill this authorization.
SlPlliltui'C ---------------X---- ------
Cl-clllatory Operatorr -------- ///-- --------------------------------
March 2015