Bruce, Richard C. 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:
T� ; 6tl
NAME: c - (71- ----
----
� ---------___---_.__.___CASE # _
DATE OF CREMATION:
TIME STARTED: _ 1 2 c — TIME COMPLETED: Z`6_0 �
TYPE OF CONTAINER: /��✓C __—C_1`�J' .Gj"D�.7 Cp�1 �� — r�, _
PLACED IN RETORT: _1?_'tc? �''1 MOVED: ._ /tF Z
—-- - ----
PLACE OF DEATH;Grw j✓j ►� Ce. _-- _r hj,�,'4 �; 7 , �`S� S�. �Gra�,�?'�� �✓. 1.2(33;�
ESTIMATED WEIGHT OF REMAINS AND CONTAINER: _—
DATE & TIME REMAINS ARRIVED AT CREMATORY: .1 -- �-d-7 20;,U_ -
PLACED IN HOLD: —
PLACED IN REFRIGERATION:
RETORT ## IN WHICH REMAINS WERE CREMATED: 0,-
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SHALL 13E RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
No&Ycr.5: is
NEW YORK f Department of State
STATE OF Division or DIVISION OF CEMETERIES
OPPORTUNITY- Cemeteries One C-rrtmc,ce P+azz
v9 We:sh rg;on A re'wc
Aiba y.NY 12231.00 '
Tc•iepnonc :518)4746226
wwv:Cos.np.;1p;
Authorization for Cremation and Disposition
This Authorization Form must be completed and signed prior to delivery of remains for cremation.
03 2.5 2G20 �7
Date. .. _ _--. !'lurnber
Cremato-y Name Pine View Crerratory
Address `, Quaker Road Queensb�ly NY 1280a 518_745_4z -7
Phone
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
1 Cremation is carried out by placing t')e remains of the deceased a•^d :ha cuntame.r holding the remains into a cremation chamber whare
they are subjected to,ntense heat ano fame The heat and flame will incinerate and consume everything except bone and metal,
which are all that will be left after cremation.
t-ollow:ng cren-aton in-, ,rernalor"v-,mll taKe reasonab e efforts to rerwve all of tf e remains and tithe' material from the cremation
chamber.bu?some minimal dust and resicue wiii i;keiy be,eft behind The crematory will separate rncidenla! and foreign material from .
the remains and the!ncicental anc foreign material wil*be disposed of as required by lave The crenated remains will be mechanically
pulverized into small pieces and placed ^to a designated roi-ta.r-er 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 hoid;ng tre ,r:-cremate^ human re r:a r,s r•.lin-,iteo circumstances. such as to confirm the
identity of the deceased or to ensure that ro material s enclosed whict,might injure ompioyees or darnage the creratory oro[rerty. If
human remains are delivered in a container which is not suitable for cremation such as ceremonial or rental casket,the
crematory will require that tho remains be moved into a suitable container before it accepts the remains. The opening of a
co^taine.,or the transfer or ramoval of rema;^s w0l ne conducted before a wiloess and Wl be done!r privacy vr.th dignity and respect.
IDENTIFICATION OF DECEASED
Richard C F3,uce Widowed
Name of Deceased Marital Status
Last Knovyr•,Address 69 i.ampllghter Acres For Edward. NY 12826
Pace of Death. Granv;!!e Center GranviLte NY
Sex 86 r 18!193a 03i25'2020 i 165
®h1 �F Age nf�B 01 Date of Death . Lshmated Weight
Description of casket,container rn whir,:^Tema^s w l'be del vexed
Fioren•ce Crernavor Container Plywood and Corr gatee cardboard
PERSON IN CONTROL OF DISPOSITION
Pers4n(51 in control of disj osihorr inival ONE of the follov.'awl
-------- I am.,'We are the des!gnaiec� ageril of ire deceased desicna!EC'J'.a 1"till rr written instr zment executed pursuant to Public
Health Law Sectoor• 4201
-OR-
'J1e have no ic-cawledge that the deceased executed a wr tter instrument pursuant to Public Health Law Section 4201 or a
vvill contaw.rig G -ecivzms`ur the disposition of t:rs or her Tema ns a^u i:we are the personas) having prorlty under Public Health Law
Section 420 i and have the right to authorize cremato-of the remains of the deceased MyiOur relationship to the deceased is as
follows
R!charc C Bruce
. _ :ro pro;•
DOS-1898-1(Rev. 08.Ib) Page 1 of 3
Authorization for Cremation and Disposition
(Insert from 11;e list below')
Number 3 DescrioGor, Any surviving child eighteen years of age or uldei
1. A person designated in writing pursuant to Public Hea't,, La•n,Section 42'1D1 3
2. The surviving spouse
2a. T^e surviving domestic partner.
3. Any survivirg ch#ld e ghteen years c;f age or o Jer
4. 4 sur iv ng parent.
5. A.Surv'ving sibling eighteen years of age or older.
G. A lawfully appointed guardian
7. Any person(s)eighteen years of age or older entrled to share in the estate and wrlo>s 3re closest in relationsnmp to the deceased
8. A duly at fiduciary of the estate.
9. A close frieny or relative who nas executed a v.,r:tte^statement pursuant to Pub',c Health Law Section 4201(7):
10. A cnief`:seal of icer ct a county or a pubic aom •stratcr appointed pursuant to the Surrogates Coart Procedure Act:
10a. .Any other person who;s acti;,g on behalf of the deceased ano who^as executed a wr Van statement pursuant to Pubic Health
Law Section 4201i''1
flnihai ALL THREE of the FollowIngi
Milt _ ��"' UWe hereby affirrn rha; t!�c oody of the deceased Goes-,ot coniain a batte y battery pack. power-ell radioactive implant.
or radioactive device and that any such materials were :emcved onoi 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.
y
UWe affirm tr.P1 nslr;actions have teen given to
regarding the removal of any personal p•operty of other tr!rg of value which any L;erson signing below or any family member of the
deceased w.shes to preserve Pine View Crematory
is not responsible for the remova! of personal Merits from tre 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
P:ne View Crremato y
IM,hereby authorize
to cremate the remains of the deceased.
FINAL DISPOSITION
The pe,s:,n authorized o receive the cremated remains 0 the deceased fron' lie crematory is.
Name M 6 Kilmer Funera: Home
Add,-ess
36 Main Sbeet. South Glens Falls NY 12oG'� 5118-745-8116
Ph.o•.,�
The cremated remains of deceased will be disposed or as UlUws
Burial at Southside Cemetery
If for any reason the person named above does not take possession of the cremated remains.
Pine View Cremator y is authorized to gave possession of
M B Kilmer Funeral Home b deliver
the remains to Y y
......., ...:'G''
in person or by registered mail
R!;;nard Bruce
DOS-1896-f(Rev 0 '.5 Page 2 of 3
Authorization for Cremation and Disposition
Ilnit;af the/cUavilligj
s_tlt I1We understand that if the remains are not claimed vvjthin 120 days of cremator
Pine View C,ematory
_. _.._—_ _— _-- _ ____.—may dispose of the retrains in
ar ir,etrievable manner such as by scattering
CREMATION CONTAINER/URN
(htifial ONE of the folfowinp)
__-___--_ An urn to be used as a:_oritainer for the cremated remains has peer purchased from
and is described as follows
I%We understand that if thin urn is too small to ho,o the entire cremated ,e rains an add tional nyid container may be used for delivery.
-OR-
An urn is^ct yet purchased I'We understand tl-at it no,:inn is purchased er otrer•,•,ise provided
---- -- ----- will place the cremated remains in
a -igid temporary container`or delivery
LrnCt'n;ti h1;;rr:hy �
`his Authorization Form -was prov,dea by �' ii was executed at
M 6 Kilmer Funeral Home
136 NRa!r Street,South Glens Falls NY 12803
and is signed by the funeral director;3s witness To nti execution
I•'We have iece ved a corncleted copy of this Authorization Form
'he person(s)idontifiod below is/are the person(s)in control of disposition,who by signing this Authorization Form,attesl(s)
to the accuracy and completeness of the Information contained in this Authorization Form and authorize(s)the foregoing.
Signed this 251h_ day of Mach 20 20__-.
r
Cheryl Leombruna ,
165 Lamplighter Aces. For!Edwa;a NY 1282E
CHRISTINE COLUM]2021
Notary Public-State of
.,.. -- Commission#GG 16
..� My Comm.Expres Dec 2
Owded Ohl NOWFW 11110141Y 1111101111 -.
WITNESS: �\ J
V
t ,
T1no_�rhy hrii rn,,u. �•—
"`'��ll
R chard C 6:uce
INeme of t)eceasem
DOS-1698•t(Rev 08115i Page 3 of 3