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Coon, Harry Pil)c; View ("en)et:cly Lac (;rclt)atot'iuttl Qualcc;r Road Qum mbury, NY 12804, (518) 745-4-477 of (.518) 74,5-447(> funeral Hone 8 IZc.clucsted Reluru 'l'in�� Nan►c___------- Date of Cremation__ /0 t l tq 'fine Startcd__.Z�nDh Placed in I Iolcl: ----------------- Placed in Ref-igen--mlolt: Placed in Rctorl: Type of Container ------�Q�V , ..---��=��rii�.....__. -- � 4 Remarks Main Move Place of Deatl, EMImat.ed Weigla ol' Remains and Container - -_ _--?10 Date&Timc Rcm-,fins arrived at.Crc nl;ctor +� 1 Name: (A l:une;ral Dircct.or or Rcgistcral Resident. f)(Aivering Remains_-----Josh Detailed ►-eason for delay if remains were ercmal.cd more than /1.8 hoUl'S Irolt) tllnC OI' aCCCI)CC l delivery ---------------- ------------------ Rctort Numbcr in which Remains wcl.c CrCIn;U.Cd_ -- _ 60...p (t-- Note:`I'I►e Crcutatiort C,og shall t)e rctainccl in tllc l)crn)ancnt. l ilc of the C rc m;ttOry NYS Department of Slate Authorization for Cremation and Disposition Division otCemeteries One Commerce Plaza,99 Washington Avenue Albany,NY 12231 (518)474-6226 www.dosmy us This Authorization Form must be completed and signed prior to delivery of remains for cremation. Date: Number: 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 heatand 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 um. Cremated remains generally are pulverized until no single fragment is recognizableg as skeletal tissue. OPENING OF CONTAINER iL 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 e conducted before a witness and will be done in privacy,with dignity and respect. IDENTIFICATION OF DECEASED 4 Name of Deceased: 05 jtiQn _ _ Marital Status r&w2 f Last Known Address: o JS4 Qen Rea r✓4 Z�� Z Place of Death: Albanq � e Ica l Ce,nter, A(he;n_y� (`lit'..--.�ZZCX _ Sex: W ❑F Age: 7.5, DOB: 01 J0S i Iq 4q Date of Death: t p ! i Estimated Weight: Description of casket/oontait'ier in which remains will be delivered: Corrugated Cardboard Box with Plywood Starmark Model#38808 PERSON IN CONTROL,OF DISPOS17UON (Person(s)in control of disposition,in 1 1 ONE of the following) I"am%We are the designated agent of the deceased designated in a will or written instrument executed prsuarit to'Pubic Health Law section 4201. ho„knowledge that the deceased executed a written instrument pursuant to Public Health Law r.; ;" ,- ' staining directions fortlte disposition of his or her remains and (Continued nextpave) } �.. Page 1 ot3 Name of Dewsssd I amd 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. MylOur relationship to the deceased is as follows: (Insert from the fist below) Number. Description: A person designated in writing pursuant to Public Health Law section 4201 (3); 2 The surviving spouse; 2a.The surviving domestic partner, 9)Any surviving child eighteen years of age or older, 4.A surviving parent; S.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 istare closest in relationship to the deceased; B.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; ed and who has executed a written statement 1Oa.Any other person who is acting on behalf of the deceas ) pursuant to Public Health Law§4201(7). Q aLALL THREE of the following) eacfive ased doss not contain a battery, battery pack,power cell,Me hereby affirm that the body of the decerad 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 A crematory personnel. #v`74gregarding Me hereby affirm that instructions have been given to(tunes,dreaorname) tr ro or other thing of value which any person signing below or any family member of the th emoval of any personal property kT'= Pine View 'rem at ory is not responsible for ains of the deceased. Personal items le removal of personal items from the container or from the rem ft in the container or with the remains will be destroyed by the cremation process and cannot be retrieved after cremation. Y µTr S 3 Pine View Crematory _ to cremate the n ".. [me hereby authorize(aamavay ame) i re ins of the deceased. FINAL DisPO i PI .N The person authorized to receive the cremated remains of the deceased from the crematory is: Name: t3 ker F n rat H me Personnel Address: 11 eensbury.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 anj'reasa�rytfe Person named above does not take possession of the cremated remains, is authorized to give possession of the remains to .01i Phe View Crem ( aker Funfaral H01102 by delivery in person or by registered mail. .:.. . i N&W of DWMsod Page the roNowing) - k 111Ne understand that if the remains are not claimed wi miay spose of the remains in an irretrievable manner, y n Pine V Cremat such as by scattering. CRFrMATION CONTAINEWU In ' t ONE or the roiloMngj e cremated remains has been purchased from An urn to be used as a container for th Baker Funeral Home and is described as follows: IMIe understand that if the um is too small to hold the entire cremated remains, an additional rigid container may be used for delivery. R- An um has not yet been purchased. INVe understand that if no um is purchased or otherwise provided ne) Pi View Crematory will place the cremated remains in a rigid temporary name container for delivery. drectThis Authorization Form was provided by(funerarOfname) Baker Funeral Home was executed at{tu wat home name] and is signed by the funeral director inu�rat Home >Yau) 11 Lafaygtte Street Queensbury New York 128t)4 g F g as witness to its execution. INVe have received a completed y of this Authorization Form• p copy The person(s)lderrtified below Ware 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 c l-ober 20 9 Typed w Pdh Nerve (O AddrM T__ Signature - jW b Address Typed or terl - signature WITNESS: x" `.� F Typed'".Prr ►led AMMO . Fun iv n re r °' All �t C Coo✓1 M, Ov OF / PJ�