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O'Sullivan, Edward Patrick Pine View Cemetery & Crematorium Quaker Road Queensbury, NY 12804 (518) 745-4477 or (518) 745-4476 FUNERAL HOME: e _D _S. REQUESTED RETURN TIME: NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS: NAME: �c��f �/5�� �c,n CASE # DATE OF CREMATION: 1/z 3 ?o TIME STARTED: �� IS TIME COMPLETED: 1Z"�0 TYPE OF CONTAINER: m4600T - ttw C. PLACED IN RETORT: /0 )1T0 MOVED: ©en ��l��� PLACE OF DEATH: C�t�S NIS 4,505 I ESTIMATED WEIGHT OF REMAINS AND CONTAINER: s L3'�slM DATE S TIME REMAINS ARRIVED AT CREMETORY: PLACED IN HOLD: PLACED IN REFRIGERATION: 1 Nq RETORT # IN WHICH REMAINS WERE CREMETED: DETAILED REASON FOR DELAY IF'REMAINS WERE CREMATED MORE THAN 48 HOURS FROM TIME OF ACCEPTED DELIVERY: NOTE: THE CREMATION LOG SHALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY. 01/22/2020 15:21 8432377967 THE UPS STORE PAGE 02/18 New York State Deperbn nt of State NEW PORK Division of DIVISION OF CEMETERIES STATE OF one Commerce Plaza OPPOMNrrY. Cemeteries 99 Washington Avenue Albany.NY 12231-0001 Telephone:(516)4-/+U26 www.dor.ny.gov Authorization for Cremation and Disposition This Author melon Form must be completed and signed prior to delivery of remains for crematlon. Date_01/18/2020 Number. Crematory Name: Pine View Crematorium Address' 51 Quaker Road, Queensbuiy, 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 remains into a cremation chamber where they are subjected to intense heat and flame. The heat and lime will incinerate and consume everything except bone and metal, which are all that will be left after cremation. Following cremation,the etematory 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 circumstanoes,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 c"ket 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 Edward PatriCk O'Sullivan Marital Status' Never Married Last Known Address: 44 Willowbrook Rd. A t. 80$ Queensbury, NY 12804 Place of Death: Glens Falls Hospital, 100 Park Street, Glens Falls, NY 12801 sex: ®M OF Age: 70 DOB: 08/27/1949 Date of Death: 01/17/2020 Estimated W ght 3 3 P Description of casket/oontainer in which remains will be delivered. Altemative Container/Corrugated Cardboard, no interior. Matthew's Casket Co. PERSON IN CONTROL OF DISPOSITION Warson(s)in control of dispositm,fnrdal ONE of the followmW I am/We are the designated agent or the deceased designated In a will or.written instrument executed pursuant to Public Health Law Section 4201_ -OR- IANe have no knowledge that the deceased executed a written instrument pursuant to Public Health Law Section 4201 or a Will containing di dions for the disposition of his or her remains and I/we are the person(s)having priority.under Public Health Law Section 4201 a have the right to authorize cremation of the remains of the deceased_ My/Our relationship to the deceased is as follows: Edward Patrick O'Sullivan nve,ns DOS-1898-f(Rev.08/15) Page 1 of 3 01/22/2020 15:21 8432377967 THE UPS STORE PAGE 03/18 Authorization for Cremation and Disposition (Insert tram the list below) Number 5 Description;Only sibling:Thomas Michael O'Sullivan 1. A person designated in writing pursuant to Public Health Law Section 4201(3), 2. The surviving spouse; ?a. The surviving domestic partner; 8. Any surviving child eighteen years of age or older; 4. A surviving parent; ft) A_surviving sibling eighteen years of age or older; 'W'� A`lawfully appolnted guardian; 7. Any person(s)eighteen years of age or older entitled to share in the estate and who is/fire closest in relationship to the deceased; & 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 Ad: 1 Any other person who is acting on behalf of the deceased and who has executed a written statement pursuant to Public Health action 4201(7). (Initial L, EE of the following I e hereby affirm that the body of the deceased does not contain a battery,battery pack, power cell,radioactive implant, or radioa i e device and that any such materials were removed prior to the execution of this Auffwft Won Form. Failure to remove items for to cremation root result In harm to the crematory and crematory personnel. ! I affirm that instructions have been given to _ Cassidy VonStettina . (Fw,cd oie�lar I�rnQ) re rding 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 Crematorium Xh-a wyNa"w) D ie for the removal of personal items from the container or from the remains of the deceased. personal Items left in the th the remains will be destroyed by the cremation pwoess and cannot be retrieved aftr cremation. hereby authorize Pine View Crematorium remains of the decreed. RNAL DISPOSITION The person authorized to receive the cremated remains of the deceased from the crematory is.- Name-Thomas Michael O'Sullivan Address: 696 Savannah Dr., Pawleys Island, SC 295W Phone- 843-314-3580 The cremated remains of deceased will be disposed of as follows: Mailed by USPS to nephew, Kevin O'Sullivan, per the request of legal next-of-kin,Thomas M_ O'Sullivan If for any reason the person named above does not take possession of the cremated remains, Pine View Crematorium is authorized to give possession or (0--hxy►-+mod the remains to Regan Denny Stafford Funeral Home by delivery FWWWr—,uam) in person or by registered mail. Edward Patrick O'Sullivan rnan.e dr�roaw� DOS-189M(Rev_08/15) Page 2 of 3 01/22/2020 15:21 8432377967 THE UPS STORE PAGE 05/18 Autbqrization for Cremation and Disposition 71, (Ind the t/wun derstand that it the remains are not claimed within 120 days of cremation, Pine View Crematorium may dispose of the remains in (Name ofCMWErvyj an irretrievable manner,such as by scatterino_ CREMATION CONTAINERfuRN !(rri W ONE of the Mowing Regan Denny Stafford An um to be used as a container for the cremated remains has been purchased from F.,Aorar w,%m— and is described as follows; Me un nd that if the um is too small to hold the entire cremated remains,an additional rigid container may be used for delivery. -OR- 'id urn is not yet purchased_ Me understand that if no urn is purchased or otherwise provided Pine View Crematorium will place the cremated remains in a rigid temporary container for delivery. This Authorization Form was provided by _ _ Cassidy VonStettina was executed at 91ffM+s+P*_W rwrny Regan Denny Stafford Funeral Home rFirragrat►lome rJers) 53 Quaker Road, Queensbury, NY 12804 -- ffik.-rr anc,add and is signed by the funeral director as witness to Its execution. r IANe have received a completed copy of this AuUrvriz Wm Form_ The person(s)identified below Is/are the person(s)in control of disposition,who by signing this Auakwh atlon F*nn,all;Wst(s) to the accuracy and completeness of the information contained In this Authorization Form and authorizes)the lForegoing. Signed this 18th day of January 0 Thomas Michael O'Sullivan J T�ysd or F}e(.d nrnrQ 696 Savannah Dr., Pawleys Island, SC 295W Ackkmz WIT ESS: \ �\�C_ f nievf r Typed a Ahr ) (Fwru.�D:ec�r s+a+ ► Edward Patrick O'Sullivan (Mom oroo 9-4 DOS-18984(Rev.W15) Page 3 of 3