Santos,Emanuel William a
Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME:
REQUESTED RETURN TIME: �✓OhG
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
KeX-tY
NAME: ��gnufj— 7�9 CASE #
DATE OF CREMATION:
TIME STARTED: � TIME COMPLETED: y
TYPE OF CONTAINER: C-01 R-Aq� -cs-, hrr 1A plyk0oJ
PLACED IN RETORT: MOVED:
PLACE OF DEATH: 1✓ ( ,Y e-,(4L gr<, Gender Tn(-
ESTIMATED WEIGHT OF REMAINS AND CONTAINER: l`�O j6S
DATE & TIME REMAINS ARRIVED AT CREMATORY:
PLACED IN HOLD:
PLACED IN REFRIGERATION: /,�� ►�+ 3'ry��0�0
RETORT # IN WHICH REMAINS WERE CREMATED: S-,oer
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
Authc. .'zation for Cremation and Disposition Division ofCemeteries
One Commerce Plaza,99 Washington Avenue
Albany,NY 12231
(518)474-6226
www.dos.ny.us
Tt;. i{�r�ri ration Form must be completed and signed prior to delivery of remains for cremation.
Date: o,-' � Number:
Crerrm?±-_ ^' Pine View Crematory
Address Quaker Road, Queensbury, New York 12804 Phone: 518)745-4477
CREMA-.-.ON IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremat'cD.n is carried out by placing the remains of the deceased and the container holding the remains into a
crematio i cnamber where they are subjected to intense heatand flame.The heat and flame will incinerate and consume
everything e;:cc� tiona and metal,which are all that will be left after cremation.
Follcw r c crprr a4_i3n, the crematory will take reasonable efforts to remove an ofthe remains and other material from the
crema-:_ c„ e , buc some minimal dust and residue will likely be left behind. The crematory will separate incidental and
foreign 3ter_ rom the remains and the incidental and foreign material will be disposed of as required by law. The
crematec remains wi!': be mechanically pulverized into small pieces and placed into a designated container or urn. Cremated
remains ganeraiiy are puiverized until no single fragment is recognizable as skeletal tissue.
OPENIN( !ji Cji,4'iAiNER
The crer ;r r „ enly open the container holding the un-cremated human remains in limited circumstances, such as to
confirm = icer. or the deceased or to ensure that no material is enclosed which might injure employees or damage
cremator rc)o,- :=human remains are delivered in a container which is not suitable for cremation such as a ceremonial or
rental cas : , t'..- : ::a::P:atory wil". require that the remains be moved into a suitable container before it accepts the remains.The
opener. c':e transfer or removal of remains will be conducted before a witness and will be done in privacy,
with d:-n. -:,:=c--..
(DENT.7= �� ,=D
r L
Name cL Ce _ `t�(}1 (1 {QS Marital Status: 'Jdooej
Last _._eSsr 1c. �b(ellu,
I
Place of Death- f
Sex: `, _ DOES: ' Da of Dea : a?J $ 2ZO Estimated Weight`
)escriv i r. which remains will be delivered:
--d .ar-board Box with Plywood Starmark Model # 38808
1ERSO lL j,- °0S!TION
Perso; ;s, initial ONE of the following)
w -d agent of the deceased designated in a will or written instrument executed pursuant to Public
lealth Lain- section 4201.
-O R-
\r _ nave <^:owledge that the deceased executed a written instrument pursuant to Public Health Law section 4201 of
3 will con-Lalnirig d �eci:ions for the disposition of his or her remains and (Continued next page)
]Lna
DOS-1898-f-;(Rev.01/10) Name of Deceased Page 2 of 3
I am/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:
(Insert from the list below)
Number:- Description:
A person designated in writing pursua o Public Health Law section 4201 (3);
2. The surviving spouse;
2a. Tne surviving domestic partner;
O ,any surviving child eighteen years of age or older;
4. ' sur,',,;r.g Iarent;
1-. t� su w°ving sibling eighteen years of age or older;
!avifuYr appointed guardian;
n r(s) eighteen years of age or older entitled to share in the estate and who is/are closest in
t.: the deceased;
'`. lul;i appointed fiduciary of the estate;
c or relative who has executed a written statement pursuant to Public Health Law§4201(7);
0. ch`<_` "scE:' officer of a county or a public administrator appointed pursuant to the Surrogate's Court
Oa. �_.- i; rson w"o is acting on behalf of the deceased and who has executed a written statement pursuant
Pt b" =: " '.aw U42C1(7).
lnit,co ALA ;-H,_—E -,J cr c following)
l v'z r .icy affirir,that the body of the deceased does not contain a battery, battery pack, power cell, radioactive
imp.ant, ci aeJicc and that any such materials were removed prior to the execution of this Authorization Form.
Fail_:„ _ -ase iter•:s prior to cremation may result in harm to the crematory and crematory personnel.
"A /4ve hereby affirm that instructions have been given to(funeral director name) Cassia Rafferty#14100 regarding the
removal or ar,, je: 3.,a', p.operty or other thing of value which any person signing below or any family member of the deceased
wis_, c c,enMoto,y r:oirej Pine View Crematory is not responsible for removal of personal
ite:. _.:r.e, rcr;,the remains of the deceased. Personal items left in the container or with the remains will be
desk:o°y °,r _:-erriation process and cannot be retrieved after cremation.
„ize(cremotorynome; Pine View Crematory to cremate the remains of
the lec=f�s-~'.
FIR?:.-..._
The e.-scr. . .: -,zed to receive the cremated remains of the deceased from the crematory is:
Nar Baker Funeral Home Personnel
Adaress: is ,eae Steer Queensbury New York 12804 Phone: (518) 761-9303
The I-r Gir s c,Ue:;eased will be disposed of as follows:
If fl-. _ -erson named above does not take possession of the cremated remains,
(cre _ `1'ww Crematory is authorized to give possession of the remains to
(funero,'nr,re :3aKei' Funeral Home by delivery in person or by registered mail.
tMalw'dh�s
DOS-_'`- - ,,�_'�:0:.:` , Nnma of narancvd Pate 2 of 3
Initial the following)
I/We understand that if the remains are not claimed within 120 days of cremation,
(crematoryname) Pine View Crematory may dispose of the remains in an irretrievable manner,
such as by scattering.
CREMATION CONTAINER/URN
Initial ONE of the following)
r urr -3 oe used as a container for the cremated remains has been purchased from Baker
Funeral Home 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 aelivery.
-OR-
An urn nas not yet been purchased. I/We understand that if no urn is purchased or otherwise provided (crematory
name) Fine View Crematory will place the cremated remains in a rigid temporary
container for delivery.
This Authorization Form was provided by(funeral director name) Cassia Rafferty#14100
was exe�_u.ea a, iErcl.�cn;ena,ne) Baker Funeral Home
ftune-_�; -e adc'ress;_ 11 Lafayette Street, Queensbury, New York 12804 and is signed by the funeral director
as witness to its execution.
I/V!le hav , e:;3:A ca a competed copy of this Authorization Form.
The oerson(s) inentiried below is/are the person(s) in control of disposition, who by signing this Authorization
Form, ttost!s; ro t?e accuracy and completeness of the information contained in this Authorization Form and
authorize(s) `he foregoing.
Signed zhis day of 20 "' �
Types or Printed r a;rc Signature
Address
Types Signature
�ordr ss
Typed or F: Signature
�s
Wr
aff g
Cassia i�a�:ei'_'y'
Fune,_c, Director Typed er Printed Name Funeral Director Signature
Fur ;-a - au. #01130
Regis------ —.
a
DOS 8G�- Rev 0) Name of Deceased Page 3 of 3