The URL can be used to link to this page

Cicero-Viele New York State Department of State INEWYORK piVision of DIVISION OF CEMETERIES E OF One commerce Plaza ORTUNITY Cemeteries 9 Washington Avenue Albany,NY 12231 0001 Telephone:(518)474-6226 www.dos.ny.gov Authorization for Cremation and Disposition This Authorization Form must be completed and signed prior to delivery of remains for cremation. Date: 10/29/2019 Number: Crematory Name: Pine View Crematory Address: Quaker Rd., Queensbury, NY I-$01 Phone: 518-745-4477 CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS. k, Cremation is carried out by placing the remains of the deceased and the container holding the remains into a cremation chamber where I 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 THE 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 the crematory property. If human remains are delivered in a container which is not suitable for cremation such as 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: Angela Cicero-Viele Marital Status: widowed Last Known Address: Fort Hudson Nursing Home, 319 Broadway, Fort Edward, NY 12828 Place of Death: Fort Hudson Nursing Home, 319 Broadway, Fort Edward, NY 12828 Sex: 0 M ® F Age:86 DOB: 3/9/1933 Date of Death: 10/29/2019 Estimated Weight: 400 Description of casket/container in which remains will be delivered. Florence cremation casket(plywood corrugated cardboard) 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 Section 4201 or a will containing directions for the disposition of his or her remains and I/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: Angela Cicero-Viele (Name of Deceased) DOS-1898-f(Rev. 08/15) Page 1 of 3 r Authorization for Cremation and Disposition (Insert from the list below) Number: 7 Description:Any person eighteen years of age or older entitled to share in the estate and who is closest in relationshi 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 Section 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 Section 4201(7). (Initial ALL THREE of the following) _Me 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. I/We affirm that instructions have been given to Kyle Kilmer (Funeral Director Name) 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. Pine View Crematory (Crematory Name) is not responsible for the 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 Pine View Crematory (Crematory Name) to cremate the remains of the deceased. FINAL DISPOSITION The person authorized to receive the cremated remains of the deceased from the crematory is: Name: M.B. Kilmer Funeral Home Address: 82 Broadway, Fort Edward, NY 12828 Phone: 518-747-9266 The cremated remains of deceased will be disposed of as follows: Earth Burial at Union Cemetery, Fort Edward If for any reason the person named above does not take possession of the cremated remains, Pine View Crematory is authorized to give possession of (Crematory Name) the remains to M.B. Kilmer Funeral Home by delivery (Funeral Home Name) in person or by registered mail. Angela Cicero-Viele (Name of Deceased DOS-1898-f(Rev.08/15) Page 2 of 3 � 7rl NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Angela L Cicero-Viele I Female Date of Death Age If Veteran of U.S.Armed Forces, 10/29/2019 86 Years War or Dates F Place of Death Hospital,Institution or W' City,Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc 0 Manner of Death © Natural Cause Accident Homicide Suicide Undetermined Pending Uj Circumstances Investigation U' W Medical Certifier Name Title Philip Gara MD Address 319 Broadway,Fort Edward Town,New York 12828 Death Certificate Filed District Number Register Number City,Town or Village Fort Edward 5755 89 Burial Date Cemetery,Crematory or Facility Name 10/29/2019 Pine View Crematory Entombment Address 0 Cremation Queensbury Town,New York 0 Donation g Removal Date Place Removed P and/or and/or Held ?N Hold Address 'C) f1 t!1'' ❑ Date Point of Transportation Shipment p' by Common Carrier Destination ❑Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-Fort Edward 01079 Address 82 Broadway,Fort Edward,New York 12828 Name of Funeral Firm Making Disposition or to Whom j• Remains are Shipped,If Other than Above Address a I a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/29/2019 Registrar of Vital Statistics Aimee JVahoney(ECectronicatTy Signed) (signature) District Number 5755 Place Fort Edward, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z W Date of Disposition jn �) Place of Disposition LU (address) w N (section) �J� (lot number) (grave number) 0 Name of Sexton or Person in Charge of Premises r ;'-Al (p/ se print/ Z W G/ Signature � .�' Title �u DOH-1555(07/18)p 1 of 2 ` o� �i u`° { c»c ' 8i [��/»�k�/juo/ {\(m(/ NY /'YAO4 -`' ' D»^ ~ °^�c�(�`,n»� -------_-C��eNo� p1 ^—/ '/i [�~i� -- o c 3<a//c( _ ---------__��L ' ' � ---~��- Yz'»b0 J - � --�-- . ' ..cbo/t _ Yl)c 0[[�^. m' ~""' oor__ . __-__-_----_-_--_ R ---- ^mU:r�s _----_-_--_- ��Ovc _____-____ n�y��, pL"" o[7)~A(|)__3H ---�--��+`---�' � r� _-- �_ ��_ � _- E,dm»ledW'iglU of* Remains and con(«ioor D'^ Vrinic 11co1a1uo Nxxvr o[Piunen11 [)inccior or D 'xbo:/} Rcxidcni Dc|ivo/ing Dcmx'ox__ �114 ' ' -J-------- Dohkikd rcxwuo f'or delay ([remxin� worc oo:njxbd n1on d1xn �8 hoo/n hoo� hmco[� _, xcct)�td -------------------------------------'-------------------------------------- delivery Dc»oit Number iowhich Dcojnjnswcrccrco��ucd Mo(r:'Dlc Cv:oj;0i0U 1x>,311x1, \/c ��(x�ncd in U`c Pcnoxou/i 1"'i\c n[U1c C/noxk>ry y i Public Health Law Sec. 4145(2b) 0 13 b i Receipt Human remains of ' . '' ' delivered on r , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# Authorization for Cremation and Disposition (initial following) 1/11\le understand that if the remains are not claimed within 120 days of cremation, Pine View Crematory may dispose of the remains in (Name of Crematory) 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 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- _ t��An urn is not yet purchased. I/We understand that if no urn is purchased or otherwise provided Pine View Crematory will place the cremated remains in (Name of Crematory) a rigid temporary container for delivery. This Authorization Form was provided by Kyle Kilmer was executed at (Funeral Director Name) M.B. Kilmer Funeral Home 82 Broadway Fort Edward, NY 12828 (Funeral Home Name) (Funeral Home Address) and is signed by the funeral director as witness to its execution. Me 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 29th day of October 120 19 Jeffrey Curtis Typed orPnnted Name Signatu 21 Center Street, Fort Edward, NY 12828 Address Typed or Printed Name Signature Address Typed or Printed Name Signature Address WITNESS: Kyle Kilmer (Funeral Director Typed or Printed Name) (Funera D or Signature) 14607 (Registration Number) Angela Cicero-Viele (Name of Decesseo DOS-1898-f(Rev.08/15) Page 3 of 3