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Malone, Francis ' U _°(lccoNi/U/y. NY 128041. . (5) (8) 711,5'4' 77 V/' [J /8) 711,J)'/ 4.76- ----_-__--- K � Nxo y'cK(cJ -- --- '— ---------[^,, No. �� �7 //xk o[[�rmwkx, � ----��-�-7---- �mc S/u/c� � ------- _ .�« [ mx' »[cm!/llnn. - 8 � ---- Kcoxo'ks M;1111 Movc k4o"c___ |`6,, of A"xUL ----',--����-'-__------- _-__�---''-- _---- '--_ [-'stimo|cd VYx�dU o[ |<c i -------------------- koo� ' ^` ox a/1�vcd m N:mc o[ F\o�cm| �)' ---~==�z�/--------- m. mx��] � [)d»ljcJmo'v` x. ,|J^y J,uom�o, p -������'������� o - ddiwcry ,n� um`�/c'} n«»'Q d`*) '18 |xxx� [nxo |inn o[xccc/Ucd ---_--------------------__---__---_--_-----------__---_—' ---_-----------_-----_-----------'---_---. -------_-Rclorl /<�L .� ' '-_--_--_--_'-_ ` N�dc lln Cmox|1011 o/�U/c (�/mukxT e Authorization for Cremation and Disposition NYS Division Department of State PDivision 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: 6/3/2019 Number: ' Crematory Name: Pine View Cemetery and Crematorium Address: 21 Quaker Road, Queensbury, NY 12804 Phone: 518.745.4476 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 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: Francis Xavier Malone Marital Status: Married Last Known Address: 7 Collamer Ave., Ballston Spa, NY 12020 Place of Death: Glens Falls Hospital, Glens Falls, New York 11 401 Sex: ®M OF Age: 61 DOB: 09/23/1957 Date of Death: 05/31/2019 Estimated Weight: 260 Ibs Description of casket/container in which remains will be delivered: Cardboard and wood cremation container. 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- '� I/We have no knowledge that the deceased executed a written instrument pursuant to Public Health Law s ction 4201 or a will containing directions for the disposition of his or her remains and (Continued next page) Francis Xavier Malone nnc +ono 9 1 m.- nI iIm ., .,. n___ _ o 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: 2 Description: I, Linda M. Malone, am the wife of Francis Xavier Malone. 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 executed a written statement pursuant to Public Health Law §4201(7). (ln*ALL THREE of the following) —�— I/We hereby affirm that the body of the deceased does not contain a battery, battery pack, power cell, r did oactive implant, or radioactive device and that an such materials were removed prior y p o to the execution of this Authorization Form. Failure to remove these items prior to cremation may result in harm to the crematory and cre atory personnel. I/We hereby affirm that instructions have been given to (funeral director name) Stephen P. Hans r arding 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 Cemetery and Crematorium 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 Cemetery and Crematorium to cremate the re aims of the deceased. FINAL DISPOSITION The person authorized to receive the cremated remains of the deceased from the crematory is: Name: Stephen P. Hans, Hans Funeral Home Address: 1088 Western Ave., Albany, NY 12203 Phone: 518.489.2161 The cremated remains of deceased will be disposed of as follows: Returned to Hans Funeral Home for return to the family. it for any reason the person named above does not take possession of the cremated remains, (crematory name) Pine View Cemetery and Crematorium is authorized to give possession of the remains to (funeral home name) Hans Funeral Home by delivery in person or by registered mail. Francis Xavier Malone niti l the following) I/We understand that if the remains are not claimed within 120 days of cremation, ( matoryname)_ Pine View Cemetery and Crematorium may dispose of the remains in an irretrievable manner, such as by scattering. CREMATION CONTAINER/URN Ini i l 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- An urn has not yet been purchased. I/We understand that if no urn is purchased or otherwise provided (4matoryname) Pine View Cemetery and Crematorium will place the cremated remains in a rigid temporary container for delivery. This Authorization Form was provided by (funeral director name) Stephen P. Hans was executed at (funeral home name) Hans Funeral Home (funeral home address) 1088 Western Ave., Albany, NY 12203 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 3 rd day of June , 2019 � Linda M. Malone Typed or Printed Name ISignature 7 Collamer Ave., Ballston Spa, NY 12020 Address Typed or Printed Name Signature Address Typed or Printed Name Signature Address WITNESS: Stephen P. Hans Funeral Director Typed or Printed Name Funeral DimCtor Signature 11525 Registration Number Francis Xavier Malone