Burchard, Faithe, E h111c; vic.vv (_C111CLevy (;I'CIT1ill.C)rlUlll
Quilku Road
QLA; mbury, NY 128014,
(,) I S) 711,5-11-477 or Of 8) 74,5-4476
Honic
Rc<luctil.e<I Rccurll 'l'inTe
o.
Date of G•e;"MOoll... z Z 11__0nic Stilncrl_- 3
-.----q0�:�I'inle Cornl�ICtccl,..,•, 'Z'J'S�_
1'lacecl in 1-Iolcl: -- ---^- �-
Placed ill Ilefligeracion: --
Placed in Rccorl:
Type of Contiune;l•
/ I -_ .._.._._._.__-------
Remarks
Main
---------- ------ ---- .......... Move
Place of'Death p''`9 (Z4o
_____--•-_ -�------�►`r'.".-,,,i------Ave........._--�--����1�,_� -......�l� --- �---
Eluilawd Weil;•IIL or RMIMins and Conlaincr_ (3l) ��-
Dace&'finte Ru"milis act•ivecl at.C;renlalol'yIZ;I��
-- -- ----_..__.._.. .. ......._.---._
Namc; of Puner,tl Dircclor or Rcgisc.crcd Rcsicicnl. Dc;livcrin�; IZCIIla1nS h _. -
D¢Gvlcd reason for tlebty if rc: ilains were cre m itccl nT�rc than �I_H hours IronT time or accel>►.ed
ciclivc l'y
Retort Nunll>er in wlTicll Remains were crclll:u.ccl.._........ __.._...._.._.__._.. .-.
Notc:'I'lu; Crenjalk, 1 mg shall he itudnul in lllc PCI'Illimc m. 1 ilc ol, tlic C;rcnl:uory
i
New York State
'/-'-"1EWY0JtV* OMSIon of Depttrtrrrant of t;rmte
STATE Oi ��t:i;METERIf~S
OPPORTUNITY. 1•�enelerleS One Commerce Plaza
99 WasNngton Avenue
Albany,NY 12231-0001
Telephone:(518)4746226
Authorization for sRosi#ion
Cremation and Di www.drK,ny. o„
1
This Aafhorizatiort Form trust be completed and signed prior to delivery of remains for cremation.
Date: 11t2912019 '7Q z
Number: t-3
Crematory Name: Pine View Crematory
Address: 21 Quaker Road,Queensbory,NY 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 rernains
they are subjected to intense heat and flame. The heat and flame will incinerate Mire e o into a cremation chamber where E
which are all that will be left after cremation. + and meeai,
Following cremation,the crematory will take reasonable efforts to rertOY0 ON of the remains and other material from the rxertat3on I
chamber,but some minimal dust and residue will likely be left behind. The cram
the remains and the incidental and foreign material wig be di "will separate incidental and foreign"Wileriai from
pulverized into small dispose of as required by law_ The cremated remains VAN be mechanically
single Pis and placed Irmo a designated container or um. Cremated remains generally are puivertW Uno no
g fragment Is recognb*k 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 qure employees or damage the crematory property. K
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 wiH be conducted before a witness and will be done in privacy,with dignity and respect..
IDENTIFICATION OF 2CgfMEp
Name of Deceased: Faithe E.Surrhand
Mw'ital Status:VVIdowed
Last Known Address: 152 Sharman Ave.,Glens Falls,NY 12801
Place of Death: 152 Sherman Ave.,Gbns Fail,NY 12801
Sex: Q mM F Age.92 DOB: 12/10/1926 Date of Death: i V2at2019 Estimated Weight: 130
Description of casketicontainer in which remains will be delivered.
Florence Casket Co.minKrrxum cremation casket(plywood corrugated cardboard)
PERSON IN CONTROL OF DISPOSMON
(Person(s)in coMrot of disposition.k9w ONE of the for►owng)
I am/We are the designated agent of the deceased designated in a will or written instrument executed pt r"W to Public
Health Law Section 4201.
-OR-
ltWe have no knowiedge that the deceased executed a written instrument pursuant to Public Health Law Section 4201 or a
will raining directions for the disposition of his w her remains and Uwe are the person(s)having priority under Public Health I."
Section 4201 and have the right to authorize cremation of the remains of the deceased. MyfOur relationship to the dill"" d Is as
fags'
Faithe E.Burchard
rMOM of 00006"M
DOS-1888-f(Rev.08t15) Pale 1 of 3
Authorization for Cremation and Disposition
fInsert from the list below)
Number: 3. Description:Any sun i chid e0teen yam of ape or older
1. A person designated in writing pursuant to Public Health Law Section 4201(3);
2. The s►a ming spouse;
2a. The surviving domestic partner:
3. Any surviving child eighteen years of age or older;
4. A surviving parent;
5. A surviving siWing 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 this 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 wren statement pursuant to Public Health Law Section 4201(7);
10. A chief fiscal officer of a county or a pudic admirKstrator 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 purawt to PWAc Health
Late Section 4201(7).
Q&W AU 7HREE of the fb1kvA q)
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 thin AudWrkatbn Form. Falkllue 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 Stephanie A.G7man €
+ lw�ns7
regarding the removal of any personal property or other thing of value hich any person sigrang below or any family member of the
deceased wishes to preserve. Pine View Cremabry
formrk"=hW*j
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 crematlon.
y" UWe thereby authorize Pine View Crematory
tCa+y nwn.i
to cremate the remains of the deceased.
FINAL.D11POSITION
The person authorized to receive the cremated remains of the deceased from the crematory is:
Name:M.B.Kilmer Funeral Home
Address: 136 Main St.South Glens Fags,NY 12803 Phone: 518-745-8116
The cremated remains of deceased will be disposed of as follows:
Release to Bruce Burchwd for eventual burial at Pwm View Cemeti ry
If for any reason the person named above does not take possession of the cremated remains.
Pius Vww Crematory
is authorized to give possession of
the remains to M_B.Kilmer Funeral Nome by delivery
(Fa"Larne rtamr
in person or by registered mail.
Faiths E-Burc hard
ram.ao.+ ar
DOS-1898-f(Rev.08/15) Page 2 of 3
Authorization for Cremation and Dli"sition
(I itial the following)
AlkiI/We understand that if the remains are not claimed within 120 days of cremation.
iew Crematory
may dispose of the remains in
�AVAMF�� a
an irretrievable manner,such as by scattering.
CREMATION CONTAINERftJRN
(Initial ONE of the Wowing)
An um to be used as a container for the cremated remains has been purchased from M.R.KMw Funeral
Home
and is described as follows:Kekoo Gold Tin Urn
I/We understand that if the um is too small to hold the entire cremated remains,an additional rigid container may be used for delivery.
-OR-
An um is not yet purchased. I/We understana that if no um is purchased or otherwise provided
Pine View Crematory
will piece the cremated remains in
r at Ca-mvinry,
a rigid temporary container for delivery.
This AuVwkat/on Form was provided by Stephanie A.Gknan was exeWed at
M.B.ICprter Funeral Hoene
Fsvxst h+trne rwm.
136 Main St.South Glens Falls,NY 12803
tf<n+krar mare Addeaai
and is signed by the funeral director as witness to its execution.
I/We have received a completed copy of this Audwrizadon Form.
The person(s)Identified below Isiare the person(s)in control of disposition,who by signing this Autriorizadon Farm,attest(s)
to the accuracy and completeness of the information contained in this Audtorkadon Fam and authortte S)the foregoing.
Signed this 29th day of November ,20 19
Barbara Zimmennann
Typed a Pw"d Namr * '
298 Great Cove Rd,Roque Bkuffs,ME 04654
Ad*"s
pr*d or x'1.^.d: lJd+l7P ."z�tg8i'ttry
Adar*U
YXW4-a Pn?tad>r/9ma gar6x+
AJ""
WITNESS:
Stelilmnie A.Gilman
A, ./'`'``
L.�.
(Fu^*ret 1]rvUor Typed or Pentad lWntal (rF:r++atet O �e2
14163
ssrancn t
Faithe E.Btrehard
a0Sarw4
DOS-1698-f(Rev.08/15) Pop 3 of 3
I
New York State
J- NEWYORK Department of State
S Division TATE OF Of DNISION OF CEMETERIES j
One Commerce Plaza
UNITY- Cemeteries
99 Washington Avenue g
Albany.NY 12231-0001
Telephone:(518)474.6226 i
www,eos.ny,gov 1
Authorization for Cremation and Disposition
This Authorization Form must be completed and signed prior to delivery of remains for cremation.
11/29/2019
Date: Number.
i
Crematory Name: Pine View Crematory
Address 21 Quaker Road,Queensbury,NY 12804 518-745-4477
Phone.
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 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 i
chamber, but some minimal dust and residue will likely be left behind. The crematory will separate incidental and foreign material from j
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 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
t
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 wilt be conducted before a witness and will be done in privacy.with dignity and respect.
i
IDENTIFICATION OF DECEASED f
Faithe E.Bwchard
Name of Deceased: Marital Status: Widowed
Last Known Address: 152 Sherman Ave.,Glens Falls, NY 12801
Place of Death: 152 Sherman Ave.,Glens Falls,NY 12801
Sex: ❑M F Age:92 DOB: 12/10/192f3 Date of Death: 11/282019 Estimated Weight: 130
t
Description of casket/container in which remains will be delivered.
Florence gasket Co.minimum cremation casket(plywood corrugated cardboard)
ti
PERSON IN CONTROL OF DISPOSITION i
`s
(Person(s)in control of disposition, initial ONE of the following) s
f
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.
3
-OR-
I
I:We have no knowledge that the deceased executed a written instrument pursuant to Public Health Law Section 4201 or a
will taining directions for the disposition of his or her remains and I/we are the person(s)having priority under Public Health Law i
Section 4201 and have the right to authorize cremation of the remains of the deceased. My/Our relationship to the deceased Is as
follows:
F
Faithe E. Burchard
'Name of becea"T
DOS-1898-f(Rev.08115) Page 1 of 3
Authorization for Cremation and Disposition
(Insert from the list below)
Number: 3. Description:Any surviving child eighteen years of age or older
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).
(lni' I ALL THREE of the following)
[Me hereby affirm that the body of the aeceased does not contain a battery, battery pack, power cell,radioactive implant,
� i
f
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
I/We affirm that instructions have been given to Stephanie A.Gilman
iFunerat D,recwr 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 Namei
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: 136 Main St.South Glens Falls,NY 12803 Phone: 516-745-8116
The cremated remains of deceased will be disposed of as follows:
Release to Bruce Burchard for eventual burial at Pine View Cemetery
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
.C(ematcry Namej
the remains to M_B.Kilmer Funeral Home by delivery
;Fureiat Home Name)
in person or by registered mail.
Faithe E.Burchard
7Name of Deceased)
DOS-1898-f(Rev.08115) Page 2 of 3
Authorization for Cremation and Disposition
(Initial the following)
I/We understand that if the remains are not claimed within 120 days of cremation,
Pi iew Crematory
may dispose of the remains in
�Nanw n/C-e^+atcry
an irretrievable manner, such as by scattering.
CREMATION CONTAINERIURN
(initial ONE of the following)
An um to be used as a container for the cremated remains has been purchased from M.B. Kilmer Funeral Home
and is described as follows:Kelco Gold Tin Um
!/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 um is not yet purchased. I/We understand that if no urn is purchased or otherwise provided
Pine View Crematory
!Marne of reR'afory! will place the cremated remains in
a rigid temporary container for delivery.
This Authorization Form was provided by Stephanie A. Gilman
was executed at
Funeral Orrocror Mame
M.B.Kilmer Funeral Horne
136 Main St.South Glens Falls,NY 12803 F;,^erar Hone
(Fjnera.1 Home Addressi i
and is signed by the funeral director as witness to its execution 11
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,attests)
to the accuracy and completeness of the information contained in this Authorization Form and authorize(s)the foregoing.
Signed this 29th day of November 20 19
Barbara Zimmermann
Typed or Pnmed Name Sgneture ��
298 Great Cove Rd,Roque Bkuffs,ME 04654
Address
rrre r a Fr, reY,an a Segrrature
Address
Typed Ly Printed Mama _
5:gnature
Address
WITNESS:
Stephanie A.Gilman
,Fune(al D;redor Typed or Pr!nted kamel
14163 fFineral D+rectorr spnature!
Regrstration.umber)
Faithe E. Burchard
(Name Or Dems*d)
DOS-1898-f(Rev.08/15) Page 3 of 3