Schrack, Harold Jr. Mlle View Cemetery & CreiTlaLorlulll
Quaker Road
Queensbury, NY 12804
(.518) 745-44,77 or (518) 745-4476
Funeral Rollie _/n, ,,1j
Requested Ret1-11-11 'I'iu1e Tn 6;4 $-6-19
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- ------J/, -------Case No. /e)
Date of Cremation_—__g1 S Il� '('inlc started_-/1 '®Sf L,I'u11C Col ple(ed_---__---/Z_ L�)T 1`L
Placed in Hold:
-----------------
Placed ill Refrigeration: _3 3b .n _
7------ -
Placed in Re(orL:
"Type of Container_ �oh L�21�! �•�e�Go,__Woo �pD�T�rYl C/ �g__
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Remarks
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Main ----------------- Move ----C�_"0 il.� `1 nil
Place Ot DCalll__Z/ , L&�GL LV _S Q c. w�� J i --i 7/�o y---------
Es(iniated Weight,of Remains and Container--------1SJL
DaLe&Tinlc Rcinaills arrived at Crelllalory g_Z- t 9 3 Z
Name of Funeral Director or Rcgis(cred Resident Delivering Reliiaius jat� __
Detailed reason for delay lI remains were crelllat.ed more than 48 hours from (1111C of accepted
delivery
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Re(.ort Number in which Remains were crcnia(cd 5-4- a--A-)- vt__- -
Note:'The Cremations Log shall be rctiullC(I ill the PCI11lancilL File of t.Ilc 0-clllatory
NYS Department of State
Ac#hc�r,;zation 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: 7 - 61' l 9 Number: /r?
Crematory Name: Pine View Crematory
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 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 j
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. j
IDENTIFICATION OF DECEASED II
Name of Deceased: �-IC + d �SLh ca(' r Marital Status: ( -
Last Known Address: FS'7)� _L=,-hAp I L-e- &Joa st (a -r\ f'( a 26
Place of Death: I-F b)Crl Or 3I3Q KNI (a It,,4
Sex: ®M OF Age: DOB: Date of Death: -7 Estimated Weight: l
Description of casket/container in which remains will be delivered:
MacDonald Container Co. wood bottom cremation container
PERSON IN CONTROL OF DISPOSITION
(Person(s) in control of disposition, initial ONE of the following) j
I am/We are the designated agent of the deceased designated in a will or written instrument executed j
pursuant to Public Health Law section 4201.
I
-O
I/We have no knowledge that the deceased executed a written instrument pursuant to Public Health Law j
se ion 4201 or a will containing directions for the disposition of his or her remains and (Continued next page)
HQ,r0 Id P. Sr-b ra c f Ali
DOS-1898-f-1 (Rev.01/10) Name of Deceased Page 1 of
I am/we are the person(s) having priority under Public Health Law section 4201 and have the right to authorze
cremation of the remains of the deceased. My/Our relationship to the deceased is as follows: *
(Insert from the list below)
Number Description:
1.A person designated in writing suant 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 §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)
I/We hereby affirm that the body of the deceased does not contain a battery, battery pack, power cell,
ra( active 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 director name) Michael Miller
rega ding 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
re ins of the deceased.
FINAL DISPOSITION
The person authorized to receive the cremated remains of the deceased from the crematory is:
Name: Miller Funeral Home
Address:6357 State Rte. 30, Indian Lake, NY 12842 Phone: 518-648-0011
The cremated remains of deceased will be disposed of as follows:
Return to family
f 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
Funera/home name) Miller Funeral Home by delivery in person or by registered mail.
Id � �.X�"1 ra _ .�) �
OS-1898-f-I (Rev.01/10) Name of Deceased Page 2 of 3
thc,following)
+I/We understand that if the remains are not claimed within 120 days of cremation,
(creatoryame) Pine View Crematory may dispose of the remains in an irretrievable manner,
such as by scattering.
CREMATION CONTAINER/URN
(Initial ONE of the following)
An urn 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.
-OR-
_, 1 4AAn urn has not yet been purchased. IANe understand that if no urn is purchased or otherwise provided
(crematoryname) Pine View Crematory will place the cremated remains in a rigid temporary
container for delivery.
This Authorization Form was provided by (funeral director name) Michael Miller
was executed at (funeral home name) Miller Funeral Home
(funeral home address) 6357 State Rte. 30, Indian Lake, NY 12842 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, attests)to the accuracy and completeness of the information contained in this
Authorization Form and authorize(s) the foregoing.
Si ned this IN day of J l , 20J/2,
Piles I Ll
yped or P r d Name Sip►teturt4
Q9 n U IQr
Address
Typed or Printed Name Signature
Address
Ty
ped or Printed Name Signature
Address
WITNESS:
Michael Miller
Funeral Director Typed or Printed Name F era D'ector Signature
12463
Registration Number
K Jr,
DOS-1898-f-I (Rev.01/10) Name of Deceased Page 3 of 3
H
Pine View Cemetery and Crematorium
Policy for Opening the Container of a Deceased Human Being
Reference:
Laws, Rules and Regulations of the New York State Cemetery
Board relating to Cemeteries and Crematories, Section 1517 D
(1) Name of Person Authorizing Opening of Container:
(2) Address of Person Authorizing Opening Container
1aV6�
(3) ``S' na re of P son Authorizing Opening Container
t
(4) Date of Authorization
%15115
(5) Reason for Opening Container
100ki n - o r- blac. z � l 100
(6) Name of Funeral Director Opening Container
1a` G (�-
(7) Funeral Directors License Number
(8) Name of Crematory Personnel Assisting Opening Container
i
(9) Name of Witness to Op ning Container
i
i
(10) Date of Opening Container
i
This record shall be retained in the Permanent File of the Cemetery for
inspection by authorized personnel.
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