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Policastro, Marion Pine View Cemetery & Crematorium Quaker Road Queensbury, NY 12804 (518) 745-4477 or (518) 745-4476 FUNERAL HOME: I,_0 REQUESTED RETURN TIME: N4► NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS: GAsst(r1 U�.s�t�1� NAME: �4Noh "1 D I��O CASE # I�J DATE OF CREMATION: 7 00 A�, I ` Z 0 TIME STARTED: �0�� —TIME COMPLETED: / TYPE OF CONTAINER: Bup�ts�o ��# c Lo((tva 1,¢� OlrcLlcl PLACED IN RETORT: Q 1 MOVED: g y0 -'00 An PLACE OF DEATH: �Ie� rs 3 ESTIMATED WEIGHT OF REMAINS AND CONTAINER: I I6Y DATE & TIME REMAINS ARRIVED AT CREMATORY: 2h3l p 3'06 Ph PLACED IN HOLD: PLACED IN REFRIGERATION: 3 AT �M pp p RETORT # IN WHICH REMAINS WERE CREMATED: SLR Ug T RK 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. -- I Nevi York State <SVTATW YORK Division of �rt�R of s� Op DIVISION OF CEMETERIES ORTUNITY ��me}�r'� One Commerce Plaza 6 99 Washtn on Avenue Albany,NY 2231-0001 Telephone:(518)4M-6226 Authorization for Cremation and Disposition v+wwdos.ny.gov This Authorisation Form must be completed and signed prior to delivery of remains for cremation. Date: 02/12/2020 Number K Crematory Name: /� ?:rn '�� (WAAAWn A Address: u QAW /�6t 940,0 (,rt trr&355MEPhone; 5 �� CREMATION 13 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 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 left behind. The crematory will separate incidental and foreign mate�al from the remains and the incidental and foreign material WI11 be disposed of as required by law_ The cremated remains will be mechhnlcaliy pulverized Into small places and placed into a designated container or urn. Cremated remains generally are pulverized until no single fragment Is recognizable as skeletal tissue. I OPENING OF THE CONTAINER The crematory may only open the container holding the un-cremated human remains in limited circumstances,such as to confifm 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 wkek 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,vAth dignity and respect IDENTIFICATION OF DECEASED Name of Deceased; Marion Policastro Marital Status. Last Known Address. Place of Death: Sex: ©M M F Age- DOB: 0 () Date of Death Estimated tght ' Description of casketicontainer In which remains will be delivered. Corrugated cardboard/no interior/Buffalo Casket Co. PERSON IN CONTROL OF DISPOSITION (Person(s)in contral of disposition,ice' l ONE of the fo/Mwtiag) i I amAMe are the deaignated agont of the dacamed designated in a will or written instrument tsxwuted pursuant W Rubllc Health Law Section 4201, -OrL ! have no knowledge that the deceased executed a written instrument pursuant to Public Health Law Section 401 or a Will containina di' ctione for the e6armvai+inn nr him nr her rorn ain and 1/vnr wrw Itro paraon(o)having priority unaer i-urm.r Iaalu i Chun Secflon 4201 an have the right to authorizo cremation of the remains of the deceased. My/0ur relationship to the deceased1s as follows: - Marion Policastro D08-1898-f(Rev.08115) Pago 1 of 3 Authorization for Grernation and Disposition (Insert tiivm the list below) Numhpr- 2 description;S r+use, Peter Policaetro 1. A person designated in writing g pursuant to Public Health Law Section 4201(3); 2. Thp amrivina apounoi 2a. Thp wirv'rving domestic partner; 3. Any surviving child eighteen years of age or older, d. Q RI Ir►mrinn nnrn`.i; 5. A surviving sibling eighteen years of age or older; 8. A lawfully appointed guardian; y. 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; a A dose friend or relative who has executed a written statement pursuant to Public Health Law Section 4201(7); 10. A ief fiscal officer of a county or a public administrator appointed pursuant to the Surrogate's Court Procedure Act; 10a. ny r person who is acting on behalf of the deceased and who has executed a written statement pursuant to Public Health Law S 'on 4201(7). (filtial ACL THR of the followh?g) I _I hereby affirm that the body of the deceased does not contain a battery,battery pack,power cell,radioactive implant, or radioa a device and that any such materials were removed prior to the execution of this Authorization Form_ Failure to it%n— w ms p r to cremation may result In harm to the crematory and crematory personnel. i 7regardngth,ere �ilwwe fin that instructions have been given to Cassidy VonStettina oval of anv Dersonal nronerty or nthnrfhinp of vahio which any pamon oigning boowor any family memLco ul"Um rrw..•-�„ya w I+cocrvc- _ r-1r M;-y'lGri yI CFO 11cilVly Is not responsible for the removal of personal items from the container or from the remains of the deceased. Personal items le h in the ner or the remains will be destroyed by the creation process and cannot be re m m trinved after creation. r ^ INe reby authorize_ Pine View Crematory tD crcmatg the ins of the deceased. FI U$ITION The person authorized to receive the cremated remains of the deceased from the crematory is: i Name. Peter Policastro Address: r QA Phone; 3 The cremated remains of deceased will be disposed of as follows: t ktq 4o - Iffhr senv rpaann the nwann nam, el-O,_A- .....6 0-L P -------*-Ij. ........v, Pine View Crematory is authorized to give posserion of i file remains to Regan Denny Stafford Funeral Home by delivery (F walhbr-t m4 in person or by registered mail. Marion Policastro i DOS-1888-f(Rev-08/15) Page 12 of 3 1 I I Au;jwxizktion for Cremation and Disposition i tirretriev"able ►roWing)I/We unde tand that If the remains are not claimed within 120 days Of cremation, Pine View Crematorymay dispose of the remains in Ova"arawms�ma er,such as by scattering. NTAINERItNRN— of the fo►►owfng! An um to be used as a container for the cremated remains has been Regan penny Stafford purchased from P4,.,o.ai N.,w,o and is described as follovf: I de nd that if the um is too small to hold the entire cremated remains,an additional rlgid container may be used for doivery. i -OR`� i J�✓ An u Is not yet purchased. UWO understand that N no um is purchased or otherwise provided Pine View Cremato will place the cremated rerrfains in Pan*ofO-Obw rigid to rary container for delivery, This AW*rbadon Form was provided by Cassidy VonStettina was executed at Regan Denny Stafford Funeral Home 53 Quaker Load,Queensbury, NY 12804 ftkrnaAd�esJ and Is signed by the funeral director as witness to its execution. Me have received a completed copy of this AuthodZedon Form. The person(s)Identified below islarle the person(s)in control of disposition,who by signing this A Morimbon Form,avast( to the accuracy and completeness of the information contained in this Authorization Form and authorize(s)the foregoir g" Signed this 12th day of February _.20 Peter Policastro � G fAddrM % Addm= i Typed or at,mn nlerw sy„� Aditm WITNESS: Cassidy Von$tettina j 13709 l con Marion Policastro r�ofnra.� DOS-18984(Rev.08►15) Page 3 of 3