The URL can be used to link to this page

Nicolson, Ralph hltic; VIC.vv Cc111eCct-y & Crcttutt.oriutt) Quakcr Road Qut cnsbury, NY 128044 (,518) 746-44.77 or 0J 18) 74,5-4.4.76 I'micral Home Rectucstccl Rct.urn '1'iu)c Natttc___-------- <� �► Ntcla'so. ------------- Case No. Date: o('Cre:ntation_--�n�� t Tintc SUulccl__-_�.ys__'l'unc Contl)Ictccl•.••,__ ;UO Placed it) Placed it) Refrigeration: Placed in Retort: Type of,Cot)r�tincr ------------- ----- ------- — -- --------------- Remarks --- --------------- Main —`------ Place of Dcatlt Estimated Weigbt.of Rctitains and Cont�tinci'— If6 fl ------------- Date&'rime Rctttains arriv ' Name of 1•uncral Director or lieg'sCct'cd Resident. Delivering Reurtitts Detailed reason for delay it remains wer delivery e crcntal.ccl more lthan48 hours (C011l llllle of FICCC[)t.Cd ---------------- Retort Number in wine-1, I2etuains were crctl)�tlecl Note:T11c G•eluatioll I,og shall be retained in the Pct'Itl?tt)cnt (File of the Crcu),ttory NYS Department of State Authorization for Cremation and Disposition Division of Cemeteries One Commerce Plana,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: /c%g Ili Number. b S 9 Crematory Name: Pine View Crematory Address: Quaker Road, Queensbury, NY 12804 Phone: 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 um. 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. IDENTIFICATIONF D C Name of Deceased: f/r� W (�C�`�j(1 Marital Status: m Last Known Address: 6(D ( a t1;,rp nC4 SJ -#21ce, Qor crc" �" n o�C. s 1-t`( 12-F 'Cr, Place of Death: Aw jn U Sex: L'JM OF Age: DOB: ( 3 Date of Death: v /C Estimated Weight: 190 Description of casket/container in which remains will be delivered: S tc Y mar IL Mocia i 3TNo 8 01f r, db-a- r,,l bY)K PERSON IN CONTROL OF DISPOSITION (Person(s)in control of disposition, initial ONE of the following) ,4!3/LL , 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 -OR- lAJVe 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 h r remains and (Continued next page) j 1 co/inn DOS-1898-f-I (Rev.01110) Name of Dkewd Page 1 of 3 I amf 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. a Description: <U— _ 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, G.A lawfully appointed guardian; 7.Any person(s) eighteen years of age or older entitled to shame 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 Surrogates 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 M. (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, 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. IMe hereby affirm that instructions have been given to(fnnerai&ecbrname) Starr Baker LFD#00174 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. (aematory 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(aemefwyname) Pine View Crematory to cremate the remains of the deceased. FINAL DISPOSITION j The person authorized to receive the cremated remains of the deceased from the crematory is: Name: Baker Funeral Home Address: 11 Lafayette Street, Queensbury, NY 12804 Phone: 761-9303 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, (aematoryneme) Pine View Crematory is authorized to give possession of the remains to (funeral home oar - _ �. Baker Funeral Home by delivery in person or by registered mail. kph I\j IC(A n DOS-189844 (Rev.01/10) Name of p Page 2 of 3 (lnitia►the following) L1, I/We understand that if the remains are not claimed within 120 days of cremation, (cremakwym me) 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 um to be used as a container for the cremated remains has been purchased from ►. Baker Funeral Home and is described as follows: IMle understand that if the um is too small to hold the entire cremated remains, an addition al rigid container may be used for delivery. -OR- ,� • An um has not yet been purchased. UWe understand that if no um is purchased or otherwise provided (crematorynarrw) Pine View Crematory will place the cremated remains in a rigid temporary container for delivery. This Authorization Form was provided by(fuaeral&eotorrww) Starr Baker LFD#00174 , was executed at(fates[horse name) Baker Funeral Home (fwwWho 1e address) 11 Lafayette Street, Queensbury, NY 12804 and is signed by the funeral director as witness to its execution. I I I/We have received a completed copy of this Authorization Form. The person(s)identified below is/are the persons) 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 Qc--tU e-� ,20 jam_ Typed or Printed Name Signawry j I Address ' I Q h //1'c a%s a r-t Typed or Printed Name Signature 166 1 Sa S-DYIn,aj , icy 12 1cLa Address Typed orPrintsd Name Signature Address WITNESS: i Starr Baker LFD#00174 Funeral Director Typed or Printed Name Funeral Director Signature Funeral Home Reg.#01149 Registration Number I DOS-189844 (Rev.01110) Name of Deceased Page 3 of 3