Fish, Robert E. Pine V,i.w C �,iieCc l Y (;i L,TliII,OI'IUt11
Quakc). Road
Quec;,Mbury, NY 128014,
0) ( ) 745-11-11,77 or (,i 18) 74,5-11476'
Recluesl.ecl 12c(.ur„ '1'i,ne
Name t
Date of G e Ill;ltion_ 12-14111
l inTc Still ictl I2_ZO�. I inle Conll>ICfccl• Z:35D}'1
Placed in
Placed in lie FrigcrafiolI:
Type ofCo,jtiuncr -- u4tAC�_--•l��I �`
Rt„ruks
Main Mov(° Z'?a
Place of Death_
[•sfimat.ecl W(;iglll. OI' IZcIIT;Tins Auld Container -
-
Date&Time 11(;n1 ii,is arrivc<I ;U.Crelnat.o,' IZ I3I i�
Name: of Funeral Dircclor or Rcsicicn(. I)Clivcl.11lg Renl;lins
Del'tilccl reason Ior cleL•ly it r(:nT;lies were; (TCnlaf.ecl morc than 4.8 hours from time of ;lcecl>ted
(lelinry
Re(.ort Nulul>cr in whicl, IZcITT,tins wc,•( crc„cu.c(I
No1c:'I'lle Crenl,lUon l,o; sll;tll I)c I.Ct:(inc(I in tl,c l'cr,it,lnenl. I'il(: Of tltc C rent;llorY
bec 03 2019 04:16PM Rubey Realty 7126239967 page 2
12/02/2019 22:26 5187477548 MBKILMER PAGE 32
New'/ork sate
;'WK Oivlsl0n of oomrw rt of stele
otvom Or CMIJI IJISs
OMORTumn. C ��S One commFce Plaza
99 Washington Avenue
AlWny.W 12291.0001
rilivoene;(51814746226
www.dos.ny,gov
Authorization for Cremation and Disposition
This ALOodiaebn Pone must be OOMOefed ails doffed Prior as delivery of rwmins for cremation.
Dab:1241312019 { 1-
Number.
Crematory Name: 'I^e view Clsrttatory
Assn": 21 Quaker Road,Queer,abwy,MY 12M Phone: Sit-745.a477
CREMATION IS AN IRREVERSIBLE AND FOAL PROCESS.
Crerrlatton is tamed out by pled the remains of t11e dectimed end the conmynar how N,a remains into a cremation chamber when
they are aublected to trttanu hoot and frame. The heat and}lame lrifl Incinelrate OW Consume everything except bone and metal,
which an ON that will be left afar crafrntloru.
Follow ma cremation;the aram,atory will testa reasonable efforts to remove all d the remains and other material from to cremation
chamber,but some minimal dust end residue wit likely be Wk behind. The vornakxy wit separate incideru and foreign rnalwiai from
the remains and the Incidental and tbreign mstanai will be disposed of a required by low. The cremaled remains wit be nwhanioauy
Pulverteed into omali pieces and Plead Oft a designated container or urns. Crarnabd ralminia
single fragment is reoogni>zable as skmetel Asses. generatiy art palvariaad untie no
IZMWG OF TIME CONTAlbgg
The crematory may only open to container holding the un-cremdad human remains in limited circumstances, such as to confirm the
+dentity of the deceased or to ensure that no material is enclosed which might Iryure employeas or damage the crematory properly If
hurnan remains ere delivered In a container which is not sulhble for cremation such as ceramontai or renal casket,the
Grematory will require that the rwriatm be moved Into a suitable caftirw bettore H accepts the remaim. The opening of a
container or the translaror romovel of remains will be conducted bolas a witness all will be done In privacy,with dignity and respect.
IDENTIFICATION QLNUMER
Nome of Deceosed:Robert E Fah Marital Status:Marred
Last Known Address:46 Mechaek Street,Fort Edward, NY 12t21t
Place of Death?46 Mechanic Street,Fort Edward,NY 12628
Sex: 0 M Q F Ape:77 DOB:08f1011942 Dote of Death:11127J2019 Estimated Weight: 1E0
Description of casket/container in wttiah remains will be delivered.
Florence Casitst Co.minimum cramorbon casket(plywood conugstad ardboard►
PERSON IN CONTROL Of D,SP0111MM
(Ramon e)in confrat of 4sposidon,dt>tfN OW of Me ftlowfnq)
I w Me are the designated agent of the dsosesed designated In a will or wrGNn inaktrntent executed Pursuant to Public
Health Lew Section 4201.
.fit.
IIWa nave no knowledge[hot the deceased executed a written instrument pursuant to Public Health Law Section 4201 or a
will containing directions for the disposltlon of his or her farroins and We are the persons)having priority under Public Health Lew
Section 4201 and have the right to authorize creme[of the remaint of the decessed. f VVW rNatloftshlP to the doaeeaed Is as
fonows:
Robert E.Fish
AWW OFe.a
DOS-1898-t(Rev.08/151 Page 1 of 3
Dec 03 2019 0416PM Rubey Realty 7126239967 page 3
12/02/2013 22;26 5187477548 MWILMER PAGE 03
Authorization for Cremation and Disposition
rMMW kom lute oat below)
Number: 2 Description:The surviving spouse
I. A person designated in wrltmg pttrMN to Pubk Heath Lew Swam 42Di(3);
2. The surviving space;
2e. The oxvivmg dornaatio partner;
3. Any survtvtng child erphteen years of age or older;
♦. A surviving parent;
S. A surviving sibling eighteen years of age or drier,
e. A IaWlUiy eppordod guardian;
7, Any persart(s)eighteen years of age or older arttdled to share In the.stale aid who islare dosest in nslationship to the deceased,
A. A duty appointed Wdery of the estate;
t, A doss friend Or retetive who has ewsculed a wit"ll statement purawnt to Public Heath Law Section 4201(7);
10. A chief fiscal otUea d e county or a pubk admk►ietretor eppWod pursuant to the 9urrogsie's Court Procedure Act;
Ills. Any other person who Is acttrrp on bahetf of the deceased and who has executed a wd tan statement Pursuent to Public Health
Law Ssction 4201(1)
(La ft ALL THREE of#*NNowoW
-tL4-—Wive hereby affirm that the body of the dmosed does not oontom a battery,battlry pact,power cell.radioactive implant,
or radioactive device and that any such materials were removed puler to the execution of thle AtltbarllAd"Form. FalWa to remove
these Items prior is crentsgon ow resuh In harm to the crematory axed crematory personnel.
i ,VWe sMirm that instructions have loan given to Thy Miurlphy
+ /
regarding the removal of any pvwnal property or other thing of value whioh any parson stgninp below or any family member of the
demoted wishes to preserve Pin*View Crenstory
Pu WW Armes
is not responsible for the removal of personal items Prom the container or from the rowdWe of the dsoaased. Personal{tarns left in the
container or with the ranalrr will be destroyed by tthe c►etnation process and cannot be no trleved after cremation
_VWs hereby awft lze Pine View Crematory
reftme y war;
to cremate the remains of the daosasM.
FINAL DISPOSITION
The person authorized to receive the cremated remains of the deceased tram the crartiattsty s:
Nam!M.B.161mor Fiw*w*borne
Address 82 Sroedway Port Edward,NY 128a ,Ptone: 516-747-OM
The crertlaled remains of deceased Wit be disposed d esfollmo-
If for any reason the person named above does not lake p0694984011 of the cremated remains.
Pine View Crematory is authorized to giwe possesaon of
the romans to M s•KiOw Fussetr Ho" by dolivary
it person or by repistared riled.
Robed E.Fish
1MMrr a o.or+w
DOS-isWf(Rev.08/15) Page 2 of 9
E
,Dec 03 2019 04.17W Rubey Realty 71262399657 page 4
12/82i2BI9 22:26 5187477548 MBKILMER RAGE 04
Authorization for Cremation and Disposition
r�(rn.ibwwawf
IrWG understand that It Me remains are not cisimed wiMvn 120 days of rrama ion,
Pine View Cremmiry
ar►Krstneveble manner,such as by scananng, e4-Wat
may dispose of the rsmains in
((,QM ONE of Nte*Wo")
An um to be Wad as a conWidir for this cremated remains has been purchased from
and is described as follows:_
VWe understand that if the urn is too smeii to hold My entire cremeted memarne,an additional riofd container may be used for delivery.
.FOR
Jam,An urn is not yet purchased VWO understand that if no urn is purchased or otherwise provided
Pine View Crematory
will piece the orerneWd remains in
a rod temporary conta rw for tlalivery.
This AuNrorlistlon Forth was provided by Tenathy Miwy was examtatl W
taewr 060OW Noq
M.S.Kftar FuewW Home
82 Broadway,Fort Edward.MY 12826
and is signed by the funeral director as vMrsaa to its execution
I/We have received a completed copy of Ift AtrOmfUaaat Fo►m.
The pMort(s)WMdMd below Ware the pefaon(s)in Castrol of d4osillon,who by SiFNV INS Authw aafbn Pam,att►st(s)
to the aceuraey and Complateness of the IMomation Contained in tills AathoNxallon Form and aUtherisels)this foregoing.
Signed this 3►d dky of a0e"ber .20 19 ,
Tammy Fish
Typw of tam AwkAm
W2 East Joy Sleet.Red Oak,lows 5150
Addreaw
now or XM Now
Aaatir
TWUN v 4vnrnn
asm—
WITNESS:
Tim*"Murphy AA
!pW4,0100"W Typed a Onw/homaj
12587
Robert E.Fish
DOS-1806 i(Rav,OW15) wage 3 of 3