Whitney, Camille Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME:
REQUESTED RETURN TIME: -
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
_-A�-ltiL__ 1 ,L�� --------
NAME: �a �)�_ ,_T�Ve CASE # C 7
DATE OF CREMATION:
TIME STARTED: _ TIME COMPLETED:
TYPE OF CONTAINER: Wee _c (. A 2vJ- .Q�Y/_ ✓(Tr
PLACED IN RETORT: _--
PLACE OF DEATH:
ESTIMATED WEIGHT OF REMAINS AND CONTAINER:
DATE & TIME REMAINS ARRIVED AT CREMATORY:
PLACED IN HOLD:
PLACED IN REFRIGERATION: _ 3zi__v _-
RETORT # IN WHICH REMAINS WERE CREMATED: u)c9�._��,- -________!_._,
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
Authorization for Cremation and Disposition Division of Cemeterips
_')r" ornmPf':ft Pfala,99 Washington Avenue
Albany,NY 12231
(518)474.6226
www.do%state ny u%
This Authorization Form must be completed and sign riot to delivery of remains for cremation.
Date. 03/16/2020 Number:
Crematory Name Pine View Cre�mtory
Address 21 Quaker Road, Oueensbury, NY 12804 Phone: (518) 745-4477
F
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation is carved 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
I the cremation chamber, but sorne 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 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 properly. 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
Name of Deceased Camille Whitney Marital Status: Never Married
Last Known Addr(-,ss 188 Riggles Road, Saratoga Springs, NY 12866
Place of Death 188 Riggles Roac, Saratoga Springs, NY 12866
Sex: EIM XF Age: 58 DOB 07/0911961 Date of Death 03/15/2020 F%timated Weight:
Description of casket/container in which remains will be delivered
Connecticut Casket Cremation Container w/wooden base
PERSON IN CONT 0 OFD O5fT19N
(Person(,)in contra(of disposition, ;niti',31 ONE of the following)
ami We are the designated agent of the deceased designated in a will or written instrument executed
pursuant to Public Health L.Jw section 4201
OR
I/Wt, have no kficivviedye lhdt MC ClUt(&,P(! PXUICLA(ld J wrrttr�n instrument pursuant to Public Health Law
section -1?0 1 ()r will containing directions for the disposition of his or her remains and (Continued next page)
Camille Whitney
rage 1 (if 3
I arv/ we are the person(5) 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 f-orri the lisr below)
Number 5 Description: William Whitney (Brother)
1. A person de,�ignated in writing ptil"Aiant 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 oider,
6. A lawfully appointed guardian.
7. Any persun(,,,) eighteen years of age or older entitled to share in the estate and who is/are closest in
reiationship to the deceased,
8. A duly appointed fiduciary of the estate,
9. A c:lo,,e friend or relative who has executed a written statement pursuant to Public Health Law §4201(7):
10. A chief ffscai officer of a county or a public administrator appointed pursuant to the Surrogate", Court
Procedure Act
10a. Any tither person who is acting on behalf of the deceased and who has executed a written statement
pursuant to Public Health Law §4201(7)
L/nI(ai ALL TFIRt I of the foflowr7q)
Mle hereby affirm that the body of the deceased clues 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.
�j Me her eby affirm that instructions have been given to R-olla-n,d, -G. Hoag
regarding the removal of any personal property or other thing of value which any person signing below or any family
member of Vie deceased wishu,, to preserve Pine View Crematory_ _ is not
responsible for 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.
IAI 0
/vT17_ Me hereby authorize £c,fwj,iio,i,o,w,,/ Pine View Crematory to cremate the
remains of the deceased.
FINAL DISPOSITION
Ffl(,' person authorized to ecove the Cremated r0l"T1,1111', of the deceased from the crematory is
Name- Compassionate Funeral Carejnc.
Adr1ri,-,;,, 402 Maple Ave , Saratoga Springs, NY 12866 Phone- (518) 584-4844
The cremated ,,omains of deceased will be disposed of as follows
Gerald B.H. Solomon Saratoga National Cemetery
If for any reason the person named above does not taki, possession of the cremated remains,
Pine View Crematory is authorized to give possession of the remains to
Compassionate Funeral Care, Inc, by delivery in person or by registered mail,
Camille Whitney
I Paqe 2 -)1 3
�J'
I/We understand that if the rornains are not Maimed within 120 days of cremation,
11'IfTIO, Pine View Cremator
------ _y may dispose of the remains in an irretrievable manner,
such as by scattering.
CREMATION CONTAINER/URN
(j!jitial ONE of the following)
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,
W,ecl foi delivery
-OR-
An urn has not yet been pLlf(,Iia5e(J Me understand that if no Urn is purchased or otherwise provided
Pine View Crematory Will place the cremated remains in a rigid temporary
container for delivery.
This Author!zotion Form was provided by iiroo...... ei Rolland-I-la-nd--G.--Hoqg.......
was executed at itttoeral tinmo name) Compassionate Funeral Care., Inc
f,,fw,o _402_Maple Ave., Saratoga Springs, NY 12866 and is signed by the funeral director
as witness to its execution.
1,1lNe have rf,ceived a completed copy of this Authorization Form
The person(s) identified below is/are the person(s) in control of disposition, who by signing this
Authorization Form,attest(s) to the accuracy and completeness of the information contained in this
Authorization Form and authorize(s)the foregoing.
Signed this 16th day of March 20 20
William Whitney
Typed,,P... V
4604 Oak Springs Drive, Flower Mound, TX 75028
P"w dVI-c
WITNESS: -4r\
Rolland G. Hoag
11636
Camille Whitney
V'm!�o,0o, Face 3 of 3