Mannin, Mary Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME:
REQUESTED RETURN TIME: ooA v—
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
_AA U8.1oic
NAME: AI�r� SAG N n AQ CASE # �
DATE OF CREMATION: 31 13(Lo
TIME STARTED: 9;Nb AnTIME COMPLETED: j'.-S6pr
TYPE OF CONTAINER:
PLACED IN RETORT: s MOVED:
PLACE OF DEATH: _flifln s Pl)S hose l l�)
ESTIMATED WEIGHT OF REMAINS AND CONTAINER: ,
DATE & TIME REMAINS ARRIVED AT CREMATORY:
PLACED IN HOLD: A ;0pm
PLACED IN REFRIGERATION: (�
RETORT # IN WHICH REMAINS WERE CREMATED: V _
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.
NYS Department of State
es
AutF orization for Cremation and Disposition Division of on Avenue
One Commerce Plaza,98 Washingttoue
Albany,NY 12231
(518)474-6226
www.dos.state.ny.us
This Authorization Form must be completed and signed prior to delivery of remains for cremation.
Date:
��ll Number: 3 G
// d 12V
Crematory Name:
���� e��ir�
Address: Phone:S J�
� �� '
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
ns an
consume everything except bone and metal,which are all that will be left after cremation.
Following cremation,the cremato m niimal dust andll take aesidue will likely beble efforts to Veeft behind.The all of the tcrematory wildi other l material from
om
the cremation chamber, but some
incidental and foreign material from the remains and the in and foreign material will be disposed o as
required by law.The cremated remains will be mechanically pulverized into small pieces and placed into a
designated container or um. Cremated remains generally are pulverized until no single fragment is
recognizable as skeletal tissue.
OPENING OF 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 crematory property. If human remains are.delivered in a container which is not suitable for cremation
such as a 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
Marital Status: Ojodnt�,0
Name of Deceased: /Z
Last Known Address:
Place of Death: C Vf.
Sex: ❑ME Abe:
DOB: Date of�th---� /�L'-�Es"�mated�We'ght�Z40—
Description of casket/container in which remains will be delivered:
PP RS IN CONTROL OF DISPOSITION
(Person(s)in control of disposition, initi 1 ONE of the following)
I am/We are the designated agent of the deceased designated in a will or written instrument executed
pursuant to Public Health Law section 4201.
-OR-
1,Aa.-_ I/We 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 (Gwn n �/
Page 1 of 3
Name of Doc"
DOS-1898-f-I (Rev.01110)
I aW we 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:
(►nsert from the list t erow)
Number:_ Description: O M-01-Ak
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 istare 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§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§4201(7).
(initial ALL THREE of the following)
AQ_I/We 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
Authorization Form. Failure to remove these items prior to cremation may result in harm to the crematory and
crematory personnel. t`, AP'k ;.I
_I/We hereby affirm that instructions have been given to hune ardrn3aorname) l�
x regarding the removal of any personal property or other thing of slue which any person si ning below or any family
member of the deceased wishes to preserve. (crematory name) �itJt d L C'"c f is not
responsible for removal of personal items from the container or from the remains of the decreased. Personal items
left in the container or with the remains will be destroyed by the cremation process and cannot be retrieved
after cremation. ,,
UWe hereby authorize taematory ? '�d/ � � A-X F '�l �f GlV 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:
Address: i r� U1'1� f4 - � Phone
The mated remains of deceased will be disposed of as follows:
If for any reason person named hove does not take possession of the cremated remains,
is authorized to give possession of the remains to
icremawy navel
�— by delivery in person or by registered mail.
(lunerat Home nanre)
Name of!)soeased Rage 2 a 3
DOS-l8gg{a (Rev.01110)
Y-.
(k( he following)
Ime understand that if ins a t clai within 120 days of cremation,
(aemetoryname) / rJc may dispose of the remains in an irretrievable manner,
such as by scattering.
CREMATION,CONTAINER/URN a
(initial ONE of the following).
An um to be used as a container for the cremated remains has been purchased from
and is described as follows:
1NUe understand that if the um is too small to hold the entire cremated remains,an additional rigid container may be
used for delivery.
0 -
An um not yet been purchased. I/We understand that if no um is purchased or otherwise provided
low) /it9 t_t9 f �C'AIA 4lti� will place the cremated remains in a rigid temporary
container for delivery.
This Authorization Form was provid by(ru name
was executed at mw mw home name}
(funere!home /and is signed by the funeral director
as witness to its execution.
I/We have received a completed copy of this Authorization Form.
The person(s)identified below hdare the persons)in control of disposition,who by signing this
Authorization Form,attests)to the accuracy and completeness of the information contained in this
Authorization Form and authorize(s)the foregoing.
Signed this / /'-'i— day of '�'``�� 20
Amher . OU inn
Typed or P&Md Name
Address
Typed or Printed Name Signature
Address
Typed or Printed Name
Address
W TN SS:
✓� G
F Director Typed ar ' led Funeral Director Sipratrue
R960i1ftn Nuffiber
f AC
DOS-IMS44 (Rev.Oitto) of Page 3 of 3