Loeber, David Jr. I
Mlle View Cemetery & CrelTlatol-luill
(,quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 74.5-4476
Funeral Home
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Requested Return `hnic�AQ�Q�___
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Date of Crenlalion -y_3.Jx i 9 _rime Startc(I-e)751/4_ji'inlc ConipIcte(l.__/-0I 9,+"1
Placed in 1-I01d:
Placed in Refrigeration:
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Placed in Retort: _d 7 5 Ao-*i-_
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rI'ypc of CollGtincr ��r/ Co, J3a�t�_ � h P�-J-P 5 c✓`�rh�t� BgQ�
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Remarks ---------------------
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Main ----e?-5 5�m--------------- ------------ Move----v-g 2z Pfn'1
Place of Dcath_ G/2n 5J�A kcs� I q4�0/-Iens r'-11 s " /- i-----------
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hslinlated Weight.of Remains andandC011lalllcl'________��l�_/7 S __Ste.ld a l01 4-5-_- I
Date&Time Remains arrived at Crematory--.]=29_-�4 /'i5�.,n_
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Name of Funmd Director or Registered Resident. Delivering Remai►,s�o� L fl -----
Det,dlcd reason for delay if remains were cremated more than 48 hours front tulle of accepted
delivery
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Retort Number in which Remains were crcn�alc(l�` ai �l✓v ak ___ _____ _
Note:'hhc Cremation I.og shall be retained in the Pcrrllaneut File of dic Crematory
NYS Department of State
Authorization for Cremation and Disposition Division Washington
One Commerce Plaza,99 WashingtonAvenue
Albany,NY 12231
(518)474-6226
www.dos.ny.us
This Authorization Form must.be completed and signed prior to delivery of remains for cremation.
Date: Number: LI qij
Crematory Name: Pine View Crematory
Address: Phone: 518)745-4477
Quaker Road, Queensbury, New York 12804
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 wherethey 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 an 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 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 OF DECEASED
Marital Status:
Name of Deceased:
Last Known Address:
1 Y 12�D
Place f Death: 2 O
Sex: IM ❑F Age: DOB: � 13 , Date of Death' D zo�cj Estimated Weight:
Description of casket/container in which remains will be delivered:
Corrugated Cardboard Box with Plywood Starmark Model #38808
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PERSON IN CONTROL OF DISPOSITION
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(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 Pu
Health Law section 4201.
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-OR-
5 I/We have no knowledge that the deceased executed a written instrument pursuant to Public Health Law section 42�
will containing directions for the disposition of his or her remains and (Continued next page)
DOS-1898-f-J(Rev.of/10)
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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: Description:
A person designated in writing pursuant to Public Health Law section 4201 (3);
2. The surviving spouse;
2a.The surviving domestic partner;
I Any surviving child eighteen years of age or older;
4. A surviving parent;
6. 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 Surro 9ates 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).
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Initi 1 ALL THREE of the following)
55 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.
5SI/We hereby affirm that instructions have been given to(funeral director name) Starr Baker #10159 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. (crematory name) Pine View Crematory 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(crematory name) Pine View Crematory to cremate the remains of
Ze deceased.
FINAL DISPOSITION
The person authorized to receive the cremated remains of the deceased from the crematory is:
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Name: Baker Funeral Home Personnel
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Address: 11 Lafayette Street Queensbury, New York 12804 Phone: (518)761-9303
The cremated remains of deceased will be disposed of as follows:
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Return to family to be decided
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) Baker Funeral Home by delivery in person or by registered mail.
� f
Initial the following)
55 INVe understand that if the remains are not claimed wmay d dispose of the 20 days of remainsin an irretrievable manner,
(crematory name) Pine View Cremato
such as by scattering.
CREMATION CONTAINEWURN
Initial ONE of the following)
An urn to be used as a container for the cremated remains has been purchased from Baker
Funeral Home and is described as follows:
INVe understand that if the urn is too small to hold the entire cremated remains, an additional rigid container may be used
for delivery.
-OR-
:nl- S An urn has not yet been purchased. INVe understand that if no urn is purchased or otherwise provided (crematory
name) Pine View Crematorywill place the cremated remains in a rigid temporary
container for delivery.
This Authorization Form was provided by(funeral directorname)
QSSi GL �Qr�C'�'�V
was executed at(funeral home name) Baker Funeral Home
(funeral home address) 11 Lafayette Street Queensbu New York 12804 and is signed by the funeral director
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as witness to its execution.
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Me have received a completed copy of this Authorization Form. j
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.
1 20
Signed this l--�X
day of I a
T—ype�d or Printed Name T Si ure
Address
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Typed or Printed Name Signature
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ress
Typed or Printed Name Signature
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ress
WITNESS:
a SSA �a es
Funeral Director Typed or Printed Name Funee'Aatureto"r'Si-gn
Funeral Home Reg #01130
Registration Number