McLean, Stanley Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
Funeral Home ----- Q1w __--
l Requested Return Time-___-_----
Nauie------_ -------------------Case No. ----------�13f"-------
Date of Cremation '1I3J1`Z___Time Stwted-_"'J�A Time Co111plctcd--------
I�l{
Placed in Hold: ___________
Placed in Refrigeration: --
Placed in Retort: -------
Type of Container----------- ---------
---------------------fo-+�-up't--------------------------------------------
Remarks ---------------------
Main ----------------------------------------- Move----------I=0A h-I---,$_ 1
Place of Death--------5`�'1 ----i—e ro,4 - ^ `"----l'k.�---N--lZg'��.
Estimated Weight of Remains and Container-_________131D___'Js --------------------
Date &Time Remains arrived at Crematory 3_iDf1_________--
Name of Funeral Director or Registered Resident Delivering Remains__--_�9 __Ns� ____
Detailed reason for delay if remains were cremated more than 48 hours from time of accepted
delivery
---------------------------------------------------------------
--------------------------------------------------------------------------
Retort Number in which Remains were cremated__ _c ✓__-f�oAY'_ ---------
Note:The Cremation Log sliall be retained in the Permanent File of the Crematory
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: 1 1 Number:
Crematory Name: P;ne V e.ti, Crematory _
Address:Quaker Road, Queensbury, NY 12804 Phone:518-745-4477
CREMATION IS AN !PREVERSIBLE 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 "_,t some minimal dust and residue will likely be left behind. The crematory will separate
incidental and foreian materiai 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 1jrn. (:remated remains generally are pulverized until no single fragment is
recognizable as skeieNak tissue.
OPENING OF COi�-;Ad"
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 prop^r+,i. If human remains are delivered in a container which is not suitable for cremation
such as a ceremonial or -eetal casket, the crematory will require that the remains be moved into a suitable
container b fcro _. -ac_ 3 the remains. The opening of a container or the transfer or removal of remains will be
conducted be`ore G ^.ir es -a-ij .vil! be done in privacy, with dignity and respect.
IDENTIFICAY�ON OF L)-' 'E'� i;Eiy
Name of Ce;ease .:_ Ac p AN
Status:
C�T Last Known Address:,"+? �(k 0-1 din 1? �l a 11 AN ) 7--
Place of Death: t4tA�o
Sex: ®M OF Age: 7 COB: R�N Date of Death: 7 Estimated Weight:.
Description of casket/cc;! &.' ier in which remains will be delivered:
MacDonald Container cremation container
PERSON IN CONTROL ,:E= DiSPOSITION
(Person(s) in contrcl c` :i _ i:: .:, inirial ONE of the following)
I am/We are t-e designated agent of the deceased designated in a will or written instrument executed
pursuant to Public i-laalt.- '_c.Al section 4201.
I/We have no r:�o:, edge that the deceased executed a written instrument pursuant to Public Health Law
jc"tione420`1 or a &-ections for the disposition of his or her remains and (Continued next page)
�f /�'f C L
DOS-1898-f-I (Rev 01/10) 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 authorise
cremation of the remains of the deceased. My/Our relationship to the deceased is as follows:
(Insert from the list below)
Number:_ Description: SIODuSe.
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 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 executes a written statement
pursuant to Public Health Law §4201(7).
(Initial ALL THREE of the following)
e hereby affirm that the body of the deceased does not contain a battery, battery pack, power cell,
AiZodactive implant, or radioactive device and that any such materials were removed prior`() t'-:e 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 d/rector name) Michael Miller
garding 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.
/We hereby authorize (crematory name) Pine View Crematory to cremate the
ains 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
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) Miller Funeral Home by delivery in person or by registered mail.
�C644
DOS-1898-f-I (Rev.01/10) Name of Decease Page 2 of 3
(1 vial the follov,,ing)
e understa.-:' _.-:a, the remains are not claimed within 120 days of cremation,
rematoryname) 'ine 1°iew Cr�, �°ory may dispose of the remains in an irretrievable manner,
such as by scattering.
CREMATION .;QNYA iN R J',RN
(Initial ONE of the foi-avvinc
An U:"' tc ~e user, as a container for the cremated remains has been purchased from
and is described as follows:
UWe understand th .-` if-,-.e ,_;,: is teo sma!', to hold the entire cremated remains, an additional rigid container may be
used for delivery.
R-
r• Urn hzs been purchased. I/We understand that if no urn is purchased or otherwise provided
�crematory narmal_ `r `� _` __� - will place the cremated remains in a rigid temporary
container'IC: (,e'ive.`.'.
This Authcr' 2:'13n red by ;"u,neral director name) Michael Miller
f M -"'Ier Funeral Home
was execute ;.- .•t ..
(funeral home as:—:
>:�7 v.u.:- �:e.30�ian Lake, 12842 and is signed by the funeral director
�;� �.
as witness to its executici-.
UWe have rec,n iveN a Co.- rec - r, of t'^�s Authorization Form.
The person':` id _.afic _ ss-,are person(s) in control of disposition, who by signing this
Authorizat or, = r , ,:°:.s� s �o the accuracy and completeness of the information contained in this
Authorization; Fora and a,ithorize(s) the foregoing.
d
Signed this ---I-- — -- - " :,° -)f U t , 20
Typed or Prin ea lvame
JC4l 9 ^-�/ O l nd c a
Address
Typed or Printer , n.. Signature
Address
Typed or PrinteC Na!ne Signature
Address
WITNESS:
Michael Milse,- 4'�g�t
Funeral Director Typed o; 'nnte ur.a Funeral D ector ignatur
l f W- V
12463
Registration Number
C
DOS-1898-f-1 (Rev. 01/1 Cl Name of Dece d Page 3 of 3