Kingsley Sr., Donald Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: Al"AylOw_
REQUESTED RETURN TIME: Now
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
DAB qu:�A►1PEQ.
NAME: �unc�Q ���cs��l S� . CASE #
DATE OF CREMATION: �Q
TIME STARTED: i6pn TIME COMPLETED: 3.2 Qh
_ I f —�
TYPE OF CONTAINER: �10(lAee - MIAI^v,`. lArCLIM(ci
PLACED IN RETORT: t0{ MOVED: �N1
PLACE OF DEATH:
►olci �irke,— 5},.t lou,Lto - 17993
ESTIMATED WEIGHT OF REMAINS AND CONTAINER: l So As
DATE & TIME REMAINS ARRIVED AT CREMATORY: 076170 ]Z,"3b f
PLACED IN HOLD:
PLACED IN REFRIGERATION:
RETORT # IN WHICH REMAINS WERE CREMATED: frwma fkij.
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.
r
Now 17 s,j;nte
NEW YORK Division of Department of State
STATE OF DIVISION OF CEMETERIES
OPPORTUNITY. Cemeteries f'914��nlnq'-�• 4v." .
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Authorization for Cremation and Disposition www Ana
This Authorizarion Form must be completed and signed prior to delivery of remains for cremation.
Date 01/25/2020 �q
Numrer I
Crematory Name Pine View Crematory
Andress 21 Quaker Rd., Queensbury• NY 12804 Phonp C�$� 7yt;_►�,
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS
C•+,ranrw Ii carried out[ry p!a,.=.y tn(a err ,ur s Of the -w:edsen and the container holding the remains into a cremation chamber where
thp, a'. &jiected to inte+.se r,r-at art!+' —e- The heat and Hams will incinerate and consume everything except bone and metal,
which are all that will be left alter cremation
ti•Pr;nq r.rrrlratinr; the rem as ,tv rnl rake rpasoriat'iso at-rta•,. -move all of the remains and other material from the cremation
Hr drrC,W nU'+,;,ern.. 11).rttt.14 ,1-.1,0 trH+°:'ta'evil'°,kP"y pp irfl r-poitttf f i,'p .rt-w j!,:"V will separate,n(ciprital and foreign material from
rs'IJrnfr.dre.1 H,t Ir,e...Jr+*►tt►i dr y' ,rsr y[ '"rrP+•7° hill ra 1SP Ar• Of d, 1-1,1111ild tly law The cre-died temalns will tie mechanically
1tr,v.rua f Intc,sma:p PT PS ►r n ri,acofl inn- a rc.•,.,t, -tir T :•tt, ,,. r ,•• Cremated remains generaily are pulverized until no
single fragment is recognizable as skeletal tissue
OPENING OF THE CONTAINER
Th: :""i"l,alrnry , av gin:, open thc• container holding the un-crernated human remains In limited circumstances such as to confirm the
dentity 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 t!elore a witness and will be done n privacy with dignity and respec!
IDENTIFICATION OF DECEASED
Name of neceased Donald J Kingsley, Sr Marital Status Widowed
Last i•nown Address 766 Sail Club Rd., Hartsville. South Carolina 12995
Pace of Death Elderwood at Ticonderoga. 1019 Wicker St Ticonderoga NY 12883
Sex ®M ❑ F Age 90 Doe 10/24/1929 Date of Death 01/25/2020 _ Estimated Weight 150
Descuphon or casket/container in which remains will be delivered
Florence -minimum cardboard
PERSON IN CONTROL OF DISPOSITION
'r•':; t rt' ,lretr=,r, Ct!d75pPSdrrx�MrlrrQi 7f of the following)
am/We are the designated agent of the deceased designated in a will or written Instrument executed pursuant to Public
rfeaith _aw Section 4201
;n
• _ IrIVP ha;a no knowledge their "F ::tp •P-►�c•.!executed + w'..rrun i•�tilri,ti-,Nt y., ,1 '�! t=nr. ,r^ c, i• in'.c Health Law Section 4..01 or ;,
l talaunq 4!oclwns for the dispose?tun A nsS ,r t,et ;emains anrt 1%va r�tha I rcr,rs. , t• ,,..,•,. a re _ c avini�, ,, ry under Public Health Law
r•'..,• 4,' 11 .teal hav( the right to author eta ;,ren alit.+' ,-f the remrr n+ �f 1h* „t•,e.is.rt MylOur relationship to the deceased is as
follows
Donald J Kingsley. Sr.
)C-`,-189N 1 ,RPV 08115;
Page 1 of _�
Authorization for Cremation and Disposition
(tnSP.,f frorn the list below;
Nurntief _3. — Description Survlv[919,child
1 A oerson designated in writing nQ ClutSUar'l to Pljf)jic Healll-,Lay, Section 420 1 3)
2. The surviving spouse
2a. The surviving domestic partnet
3. Any surviving child eighteen years of age or older
4. A surviving parent
5. A surviving sibling eighteen nears of age or otcIpf
6. A lavifully appointed guardian
7. Any persons)eighteen years of age of older enif"Ied to share in trie estate and who is/are closestrn relationship to the deceased
8. A duly appointed fiduciary of the estate
9, A,close lrteiid i IPVive who has exv 'JP a stalroment pursuant to Public Health Law Section 4201f Ti
10. A `hjef tiscai officer ()f a county of a public 841"1101'91fato,appointed pursuant to the Surrogate s Court Procedure Art
10a, Any other person who is acting on behalf n"the deceased and who has executed a written statement pursuant to Public Health
k,aw%ection 4211-11 t-.
—lif-11nifial ALL T,�4?EE of the follow,inq)
Alf_,4ANe hereby Wfitnn that the body of the deceased does not contain a battery battery pack. power cpii radloartiye Implant
or radioactive device and that any such materials were removed prior to-he execution of this Authorization Form Failure to remove
these Items prior to cremation may result In harm to the crematory and crematory personnel,
'4 IMe affirm that instructions have been given to John Alexander
Aul . . ..... -------
regarding the removal of any personal property or other thing of value vv ich any oefson signing below or any family member of the
deceased wishes to preserve P:ne. -View Crematory
is r1ul 'esMnsihle for the removal of personal items from the container or floor 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 Ij KIlfWe hereby authorize Pine View Crematory
to cremate the remains of the deceased
FINAL DISPOSITION
The person authorized to receive the cremated remains of the deceased from the crematory is
'dame Alexander-Baker Funeral Home, John Alexander
Address 3809 Main Street, Warrensburg, New York 12885 Phone (518) 623-2065
The rienriatect remains of deceased will be disposed of as follows
Return to family
if to, any reason the person named above does not take possession of the cremated remain--
Pine View Crematory is authorized to give possession or
!" 4'
the fer"i3ins to Alexander-Baker Funeral Home by delivery
person or by registered mail
Donald J Kingsley, Sr
jos-1598-11!Rev 0811`1 Page 2 of
Authorization for Cremation and Disposition
v ((nitlaf me following)
kol I/We understand that if the remains are not Clalmed vr.th,n 120 days of cremation
Pine View Crematory
may dispose of the remains in
air rrretr enable manner such as by Srattenr,9
CREMATION C:ONTAINERIURN
An urn to be used as a container for the cremated remains has peen purchased from Alexander-Baker Funeral
Nnmu_
and is described as toilows
h"e understand that ,f the urn Is too small to hold the entire cremated remains an addctronai rigid container may be used for delivery
�u
T! 't.A�n urn is not vet purcnased IMe understand that o' n
o urn is pure haled or othennnse prov,ded
Pine View Crematory
will place the cremated remains in
a rigid temporary container for delivery
P
This Authorization Form was provided by John Alex
was executed at
Alexander-Baker Funeral Home
F:rwar•nvrp Nance,
3809 Main Street, Warrensburg, New York 12885
_ -- - -.
and is signed by the funeral director as witness to its execution
INWe have received a completed copv'of this Authorization Form
The person(s)identified below islare 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 25th _ day of __._ January zo 20
Barbara Leonbruno aA,
766 Sail Club Road, Hartsville, NC 12995
WITNESS:
John Alexander --
10036
Donald J Kingsley. Sr
!Nnrnr or DvcrnarQi
DOS-1898-f(Rev 08115r Page 3 of 3