Maddock, Patricia N
Pine View Cemetery & Crematorium
Quaker Road
Queerisbury, NY 12804
(518) 745-4477 or (518) 745-4476
Funeral Home
Requested Return Time----NONE--
Name------�L tR_LS� ' --M� �---------------Case No. ------------Ad-------
Date of Cremation ��15( Time Started1: OAtfTime Completed___--_113Q,E
Placed in Hold: -----------------
Placed in Refrigeration: _-_-
Placed in Retort: ___________ --
Type of Container------ G�t_r� ----- !.'�r��lOR --- (- p_� ----------------
-----------------*L 41 ----Md-- --3s to ----------------------------
Remarks ---------------------
Main ----------------------------------------- Move----------
t' 1
Place of Death------ ---------------------------
Estimated Weight of Remains and Container----- lbo __S ---------------------
Date &Time Remains arrived at Crematory----------___� dit-_-_-__-AIS-h-_
Naive of Funeral Director or Registered Resident Delivering Remains--_--_I�(�__�o� �tN�
Detailed reason for delay if remains were cremated more than 48 hours from time of accepted
delivery
-----------------------------------------------------------------------
------------------------------------------------------------
Retort Number in which Remains were cremated----------- --------------
Note:The Cremation Log shall be retained in the Permanent File of the Crematory
State
Division or memo f St
Authorization for Cremation and Disposition NYS Department o St
ries
One Commerce Plaza,99 Washington Avenue
A 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: IL I It hi Number: y11
Crematory Name: Pine View Crematory
Address: Quaker Road, Queensbury, New York 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 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.
IDENTIFICATION OF DECEASED
Name of Deceased: d d C Marital Status:
Last Known Address: 1-7 r rl l �Z$d
Place of Death:
Val f -
Sex: ❑M XF Age: DOB: Date of Death: Estimated Weight: i
)escription 000fcasket/container in which remains will be delivered:
Corrugated Cardboard Box with Plywood Starmark Model#38808
)ERSON 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.
I
-OR-
WI/We have no knowledge that the deceased executed a written instrument pursuant to Public Health Law section 4201 or
a will containing directions for the disposition of his or her remains and (Continued next page)
P .qa&L-
DOS-1898-f-1(Rev.01/10) Name of Deceased Page 2 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:, escription: art rviaoS
A person designated in writing pursuant to Public Health Law section 4201 (3);
Z. 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
ja
edure Act;
. ny other person who is acting on behalf of the deceased and who has executed a written statement pursuant
ublic Health Law§4201(7).
nni i l ALL THREE of the following)
A4-- 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.
V,G F I/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. (aematoryname) 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.
ftVI/We hereby authorize(crematory name) Pine View Crematory to cremate the remains of
the deceased.
I
FINAL DISPOSITION
The person authorized to receive the cremated remains of the deceased from the crematory is: j
Name: Baker Funeral Home Personnel j
I
Address: 11 Lafayette Street Queensbury. New York 12804 Phone: (518) 761-9303
The cremated remains of deceased will be disposed of as follows:
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.
DOS-1898-f-J(Rev.01/10) Name of Deceased Page 2 of 3
n'ti i the following)
I/We understand that if the remains are not claimed within 120 days of cremation,
(crematory name) 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 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-
MET An urn has not yet been purchased. INVe understand that if no urn is purchased or otherwise provided (crematory
name) Pine View Crematory will place the cremated remains in a rigid temporary
container for delivery.
This Authorization Form was provided by(funeral director no Starr Baker#10159
was executed at(funeral home name) Baker Funeral Home
(funeral home address) 11 Lafayette Street QueensbuN New York 12804 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 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 day of UUTC 20�.
Typed or Printed Nome Signature
i1
0—
Address
Typed or Printed Name Signature
re
Typed or Printed Name Signature
Address
WITNESS:
Starr Baker
Funeral Director Typed or Printed Name Fu or Signature
Funeral Home Reg #01130
Registration Number
l �QO�L
Page 3 of 3
DOS-1898-f-1 (Rev.01/10) Name of Deceased