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Warner Tommy Joe Pine View Cemetery & Crematorium Quaker Road Queensbury, NY 12804 (518) 745-4477 or (518) 745-4476 FUNERAL HOME: kPa a 7,0 JAA-( N� REQUESTED RETURN TIME: 4//9 NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS: 14r'�{ �JP S;ruotii,o j NAME: Tw�Ya P G2 rw CASE # / DATE OF CREMATION: 2- a 2-ZUz6 TIME STARTED: J ,,� TIME COMPLETED: TYPE OF CONTAINER: u � �Q C�sk�� ©ml�a� ' 1411 n PLACED IN RETORT: Tl�� r�--- MOVED: �� r�^ / i,•� PLACE OF DEATH: /U i404 A Je.aS -F;�.((f /2)eo ESTIMATED WEIGHT OF REMAINS AND CONTAINER: b 5 DATE & TIME REMAINS ARRIVED AT CREMATORY: _��d,,,.� PLACED IN HOLD: PLACED IN REFRIGERATION: %' r^ RETORT # IN WHICH REMAINS WERE CREMATED: 'penes -N k IF 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. 4056063579 Almonte Library 01:46:54 p.m. 02-20-2020 12112 1)U.G V vwyf ri New York State INEWYORK epartment of state Division of )N OF CEMETERIES E OF One Commerce Plaza ORTUNITY Cemeteries r"'� � g !9 Washington Avenue Albany,NY 12231.0001 }phone:(518)47"226 Y f Y ti Z p� www.dos.ny.gov Authorization for Cremation and Disp f .' This Authorizadon Form must be completed and signed prior to delivery of remains for cremation. Date:02/19/2020 Number. Crematory Name: Pine View Crematory Address:Quaker Road,Queensbury NY 12804 Phone: (518)745-4476 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 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 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 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. H 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 Name of Deceased: Tommy Joe Warner Marital Status: Divorced Last Known Address: 101 South Street,Apt A,Glens Falls NY 12801 Place of Death: , 101 South Street,Apt A,Glens Falls,NY 12801 120 Sex: ®M [IF Age: 66 DOB: 06/26/1953 Date of Death: 02/11/2020 Estimated Weight Ibs Description of casket/container in which remains Will be delivered. t+M311#111.,, , Buffalo Casket Company—Alt Container �. -. ,tZ ff�' PERSON IN CONTROL OF DISPOSITION C. ti�t�( y `� 771g^ ' (Person(s)in control of disposition,irritia!ONE of the following) �YV t 1 amMe are the designated agent of the deceased designated in a will or written instrumen' �uarl14,6 Rublic Health Law Section 4201. ,...••4P O -OR- �``))rruntQK+ IANe have no knowledge that the deceased executed a written instrument pursuant to Public Health Law Section 4201 or a *S,,b tainingdirections forthe diposition of his or her remains and I/we are the persons)having priority under Public Health Law 42D1 and have the right to authorize cremation of the remains of the deceased. My/Our relationship to the deceased Is as follows: Tommy Joe Warner fives or Deceasec) �98-f(Rev.08115) Page 1 of 3 4056063579 Almonte Library 01:45:49 p.m. 02-20-2020 10112 Authorization for Cremation and Disposition ()nsetf from the list below) Number: 3 Description:Child over the age of 18 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; 5. A surviving sibling eighteen years of age or older, 6. A lawfully appointed guardian; 7. 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; 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 Act; 10a. Any other person who is acting on behalf of the deceased and who has executed a written statement pursuant to Public Health Law Section 4201(7). Initial ALL THREE of the following) x� a hW a by afrm 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 Authorization Form. Fallure to remove these items prior to cremation may result in harm to the crematory and crematory personnel. xe affirm that instructions have been given to Mark J.DeSimone (r„aew N— 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 b is not responsible for the removal of 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. e ereby authorize Pine View Crematory (G 6WIFName) to cremate the remains of the deceased. FINAL_DISPOSITION The person authorized to receive the cremated remains of the deceased from the crematory is: Name:.Lora Lin Fioretti Address:3812 State Route 149, Ft-Ann, NY 12827- Phone: (518)321-4269 The cremated remains of deceased will be disposed of as follows: Returned to family friend If for any reason the person named above does not take possession of the cremated remains, Pine View Crematory Is authorized to give possession of tGe Wy N—) the remains to Regan Denny Stafford Funeral Home by delivery (Fum,al rtwrie Name) in person or by registered mail. Tommy Joe Warner (Nees d Ommsed) DOS-1898-f(Rev.08/15) Page 2 of 3 •. . 4056063579 Almonte Library 01:46:18 p.m. 02-20-2020 11112 Authorization for Cremation and Disposition (ndial the t lowing) e understand that if the remains are not claimed within 120 days of cremation, Pine View Crematory may dispose of the remains in an irretrievable manner,such as by scattering. pbme acn�ay) CREMATION CONTAINERfURN (Initial ONE of the following) Regan Denny Stafford An urn to be used as a container for the cremated remains has been purchased from and is described as follows: I/We understand that if the urn is too small to hold the entire cremated remains,an additional rigid container may be used for delivery. -OR- n urn is not yet purchased. INVe understand that if no urn is purchased or otherwise provided Pine View Crematory will place the cremated remains in r�nraertrrory) a rigid temporary container for delivery. This Authorization Form was provided by Mark J. DeSimone was executed at - rFunsdOnckrNerrr) . Regan Denny Stafford Funeral Home rw,a,elrrdnW&W-) 53 Quaker Road,Queensbury, NY 12804 and is signed by the funeral director as witness to its execution. INVe have received a completed copy of this Authodzatlon Form. h The person(s)identified below Islare the person(s)in control of disposit (s) to the accuracy and completeness of the Information contained in this 19th February 20 Signed this day of ry ,20 Jeremy J.Warner,son TYped oR~Name 400 East Danforth Rd,Edmond Ok.73034 Phone n er—405-923-9825 Addren Typed PMW Name Address Typed or Pt~Neer Sipnefve Addrem WITNESS: aV ,`R t1it11�rrrttjF, f, Mark J. DeSimone � \! iF,e,nal 0►ector Typed"FrWed Nanrr Oeec0�5iVrrhreJ 10919k r i FPB% x3 Mahon Tommy Joe Warner rName orOeceasedr ��itj UF Owl'4>>- `rrrrrrrrttnititit�� DOS-1898-f(Rev.08115) Page 3 of 3