Thompson, Bonnie F. Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: rcttq ry.
REQUESTED RETURN TIME: opf-
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
IDua
NAME: �bka_ ur scN CASE # IZ
DATE OF CREMATION:
TIME STARTED: TIME TIME COMPLETED: 3
TYPE OF CONTAINED: 40,&a 630
Ca/l�C4 Ck61bd6
PLACED IN RETORT: �: Ph MOVED:
PLACE OF DEATH: ✓1lsi 0 VCrT[ Ica j �tfw�at�
ESTIMATED WEIGHT OF REMAINS AND CONTAINER: Zoo l�r
DATE & TIME REMAINS ARRIVED AT CREMATORY: 110 f.,30dn
PLACED IN HOLD:
PLACED IN REFRIGERATION: Q
RETORT # IN WHICH REMAINS WERE CREMATED:
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.
New York State
N EW YORK Departmera of state
division Of DIVISION OF CEMETERIES
STATE OF One Commerce Plaza
OPPORTUNITY_ Cemeteries 99 Washington Avenue
Albany,NY 12231-0001
Telephone:(518)474-6226
www.dos.ny.gov
Authorization for Cremation and Disposition
This Authorhadon Form must be completed and signed prior to delivery of remains for cremation.
Date. Z/�I Number. l Z
Crematory Name:Pine View Crematory
Address: Z (LAVAL POAP VI2-fP-)Q0(4 t2# I1M Phone: 619)?y S"Hy17
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation is carried out by placing the remains of the deceased and the cortainer holding the remains into a cremation dumber where
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)eft behind. The crematory adl separate incidental and foreign maWia►from
the remains and the incidental and foreign material will be disposed of as required by taw. The cremated remains will be mechanically
pulverized into small pieces and placed into a designated container or um. Cremated reran a 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 J
Name of Deceased: Gin AJOi e F. �J A/9 d.) Marital Status:
v [ 9�
Last Known Address:II X GSA I kP j-k)fi e a- N 01-A MAJ1 a rU tiY
Place of Death:VyiaPy)i/v' me -4 fi/ear 1, Nip,-KCf aJz' Tcc��' lz 6 4,,,),J Ny
Sex: ❑M 00 F Age-_ � DOB: Q,11 ,�Z y Date of Death:0 aS 0 20 Estimated Weight
Description of caskettoontainer in which remains will be deli v ed.
�l✓�-� c�,4 5 2 � pyj a s� C�iN f�'� iN e-- h �L e �="E 1�'r--�� C��°
PERSON IN CONTROL OF DISPOSITION
(Person(s)in control of disposiliori,initial ONE of the following)
i We are the design sec des (ic
HealthLa 4
-OR
IIWe 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 Uwe 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:
IrA)fU i-P- 0
oftworowsowo
DOS-1898-f(Rev.08115) Page 1 of 3
Authorisation for Cremation and Disposition
ffimtfrom the rrstbelow)
Number. Description:_ �Uiy V l P-j 17o CIS "
�V
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
S. A surviving sibling eighteen years of age or older;
6. A lawfully appointed guardian,
7. Any persons)eighteen years of age or older entitled to share in the estate and who islare closest in relationship t D the deceased;
S. A duly appointed fiduciary of the estate;
9. A dose friend or relative who has executed a written stwayw t pursuant to Public Health Law Section 4201(7);
10. A chief fiscal officer of a county or a public administrator appointed pursuant ro the surrogaWs,Court Procedure Act
10a. Any other perm who is acting on behalf of the deck and who has otec uted a wri ben statement pursuant to Public Health
Law Section 4201(7).
(in'' ALL THREE of the Wowing)
UWe 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 Authorisation Form. Failure to remove
these hems prior to cremation may resuft in harm to the crematory and crematory personnel.
l QG / Ir—Me affirm that Instructions have been given to Cho � i��//�
`� UWWV
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
is not responsible for the removal of lr near
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.
V — Me hereby authorise Pine brew Crematory
r +�nsl
to cremate the remains of the decease.
FINAL DISPOSITION
The person authorized to receive the cremated remains of the deceased from the crematory w:
Name.Any Staff from the Sdward L Kelly Funeral Home
Address:1019 US Rt 9 PO Box 548,Srhroon Lake,NY 12870 Phone:518-532-7177
The cremated remains of deceased will be disposed of as follows:-
tf for any reason the person named shove does not take poLonoo�f a cremated remains,
Pine View Crematory is authorized to give possession of
(ClandwAimmO
the remains to Edward L Kelly Funeral Home by delivery
IF--W Nano
in person or by registered mail. C6 k)()/ 0 IMP 5 C
�d
DOB-1888-f(Rev.Oa115) Page 2 of 3
Authorization for Cremation and Disposition
mine'the following)
I:a understand that if the remains are not claimed within 120 days of cremation,
Pine Vew Crematory may dispose of the remains in
(AlameorCremebry)
an irretrievable manner,such as by scattering.
CREMATION CONTAINERIURN
(initial ONE of the fallowing)
1 X ) 69,47—An um to be used as a miner for the cremated remains has been purchased from Edward L Kelly Funeral Home
and is described as foilows��12,4 6 ,A,-k p"/4J,SL t_
UWe understand that if the urn is too small to hold the entire cremated remains,an additional rigid container may be used for delivery.
-
OR—um' not yet purchas . I/M and nd that if um is purchased or otherwise provided
I ace tarmMated remains in
a rigid temporary container for delivery.
This Authorization Form was provided by was executed at
(FnneraiIWan�e)
Edward L Kelly Funeral Home DWedar
1019 US Rt.9,PO Box 548 Schroon Lake,NY 12870 ( Awme)
(Funeral Home Address)
and is signed by the funeral director as witness to its execution.
INVe have received a completed copy of this Authorization Form.
The person(s)identified below islare the person(s)in control of disposition,who by signing this Authorhadon Form,attests)
to the accuracy and completeness of the information contained in this Aufhori¢aiion Form and author¢e(s)the foregoing.
Signed this day of .4 r ,20t:;� _.
Tiveoo.PMed MM POi No M-1viy k1j. zgcr
Mess
T,'Ped orPnnred Home sowme
Address
Typed or PifnM Nam Sig W—
Add=
WITNESS:
(FunerafDkedorTymdorl ge�giagla) (F Signsfine)
�straron w l l (�)ryl'
ua i� E, o s o
t► or
DOS-1898-f(Rev.08115) Page 3 of 3