Morse, Evelyn I. 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:
------------_..------
NAM E: -. _----- -`�-_�-� -hw�
DATE OF CREMATION: '1"1j 2-o2,D
TIME STARTED:
—1--WW1---.......------ -------T 1 M E COMPLETED: -------'--Z
TYPE OF CONTAINER:
PLACED IN RETORT: _ MOVED:
54---------- ---
PLACE OF DEATH:
ESTIMATED WEIGHT OF REMAINS AND CONTAINER:
DATE & TIME REMAINS ARRIVED AT CREMATORY: _ -- y�i�� ?p Z,3b�}l
PLACED IN HOLD:
PLACED IN REFRIGERATION:
RETORT # IN WHICH REMAINS WERE CREMATED: ._ ZJ2lr 9 ak-
jj
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.
1 _
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NYS Department of State c
Authorization for Cremation and Disposition Dndsion of Cemeteties
One Commerce Pie ra,S9 Ydastungtat Avenue s
Albany,NY 12231
(516)474.6226
WWW dos state ny n
This Authorization Form must be completed and signed prior to delivery of remains for cremation.
Date: 0410812020 Number:_ - 20
Crematory Name: Pine View Crematory
Address: 21 Quaker Road, Queensbury, NY 12804 phone: (518) 745-4477
CREMATION IS AN IRREVERSIBLE ANO 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 sutaected 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 n-echanicaily pulverized into small pieces and placed into a
designated cortainer or urn. Cremated remains generally are pulverized until no single fragment is
recognisable as skeletal tissue.
OPENING O1F CQ.NTAMIA
The crematory may only open the container holding the un-cremated human remains in limited circumstances, such
i as to confirm the identity of the deceased or to ensure that no material is enclosed which might injure employees or
damage crematory property.It 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
i conducted before a witness and will be done in privacy,with ciigmty and respect.
i
��IIITIFICATION OF DG_EASED
Name of Deceased:
Evelyn 1.Morse Marital Status: Widowed
Last Known Address: _ 133 Lawrence Street,Apt 72, Saratoga Springs,NY 12866
I Place of Death: Wesley Health Care Center
�
Sex: ❑M OF Age: 102 0111611918 DOB: Date o. Death: 04107/2020Estimated Weight:�i(�
i
Description of casketfcontainer in which remains will be delivered:
{ Connecticut Casket Cremation Container wtwooden base
{ j!ERS h II:rnruronl AF DtSpOSITtOId
(Person($)in confr of of disposition,i W ONE of the fot(owi,ng)
_ 1 anit We are the designated agent of the deceased designated in a will or written instrument executed
pursuant to Public Health Law section 4201.
(F�OR- �
i1We have no knowledge that the deceased executed a written instrument pursuant to Public Health Law
section 4201 or a will containing directions for the disposition of his or her remains and (Continued next page.)
Evelyn t. Morse _
DOS•1898•f-t (Rev.01110) Name ofCece.-sod Page 1 d 1
1.,nJ v+r;urn tn�p+�r'.cGn(9)t>.1,•r,r��Kx y rx,ck�r I'u;i.0 f fcayn L��sctt,rxt 42p 1 artd h�vr trx�r►rant to eWtiarrr
t1r•rtL*,:On t�t.M► rernins cd ttx!c c,<emi .c4 MylOur relatronshlp to the deceased Is as follows;
Nu'M*rr: G (>,-,cr,xen: Earl K.Stewart(NophCH)
1.A ixY A-,n d`-i,nattier�t ttir.nr3 t,�,rsu.+r,c to jk$Vv r.lk-a*,h tam sttton 4201(3);
2.?Ao s-t v;-e,. "1 yppusc;
2a.Ter_ UnVePq dcrs+cM.tc partgci;
3.Any WY.ti:nr)ch.d eT� tccn)cars of man or aWr;
4.A stwveenq parent.
L A survn nq s.uAg ei"tvn gars or a,c or e4c-t;
L A taAft ay apppntcd gmiraon:
7.Any T3crson(s) ttgh:ern YcarS of ocyc of Oder crrtCCd to share in the estate artd who Ware Clowst in
Mt."50MM p to the deccascd:
Is.A duty appowt d rductary of v*rstatc:
9.A Ctosa tri��etcl tx rrtawe who ha.rRcttArd a�,Ync+ti st.9:crric�t pcssuart to I'u�'�c ftca:ut I.ax§i201(7);
10.A ctt.tf MAzi ttttcr of a county ar a ptta>t adrrzr+sz Mcr appo-WM pum a int to the 5urrog sto s Court
Proced a Act
10a.Any outer pmon wrio is attar on behalf of Uw deceased and vobo hsw exvcttcd a vvrglen%WMOrt
purwantro Puh'.t He.tth Law 54201(7).
Ca-.b-j At t 71 IRE a Im Ja�►rv+�)?
�.=�VNI/a twtctyy corm th..t Vie Wdy of t?*Ocea+red does M contain a battery,battery pick pot4cr cel.
radoac W tMV 1nt,or radosctree device and that any s(xh►ntatoriaS%VC removed pra to the ciLmAjon at O s
Authoritavon form. Fallme to remove these!tents prior to crerttatlon flay result In harm to the crematory and
crematory personnel
z c Wil a heretri x1fern that instm tons W.v bmn gYrn to n^V,.Oro%"w-el Ronand G.Hoog
reg3rdrg M rtMCvat of any pessonyt properly or other tting or vaW Wictl any person stgnix) below or any tarna`y
rrien%ber of the deceased vrishCz 10 prewrvc. krtiYrokrjA&VW) AmV+ew Crer Mety...........�.�. ig not
rcWons+ok,for re+novat of personal Komsn from tho eonta.tier or from ft rcrP4 ns of ttry deceased. Personal sterns
left in tfw eonUkwt or with the rertwin%witl be destroyed by the+cremation protest and cannot be retrieved
after Cremation.
..:� We hereby authorize k^ wy A#- ? Pino VIOW Ctt:ma:m to cremate the
rtnuins of the deceased.
�ss�Qsrzt9x
The person au'.ttontcd to(MI"r the crenutcd remairn of OV deccasc4 from U*Ceft Cory 4r
name: Compassionate Furverdt Care,m
g,W,tMs; 402 haply AM,Sara;093 Springs.NY 1280 (51S)SU-4844
The ct `Cd rcmtwts of dctcascd wul W d sp+o%cd of as feows:
Metwiry Gardens
If for arty reason the", person named atoa does W taste possesvon of thoo erertaited rccrm*na.
k.wr V1 F-.wh Pine View Ctert "Ory n nuthwited to"possession of tho rertta os to
r,,.,.Mhr.., ,.j :a Funeral Caro,rneµ�by tscsvty in persar►cx by rc :sfnc�t rr�f.
Evelyn I. Morso
W,Ito fr LRO#111f-i NotV 0 C%%Cwtwo tmrr2d7
Y
Lam_LV*o urW*fsMnd Mt it"tcmzlns.'rr rVA cta mcd w:hn 120 days of crcn-stat.
:,•.•�...,�....t_„„ __ pirt0 V±�t't Ctetn,-ttOry rnsy dspersc�Ck►rcrn��rn n an wrtttlevata'a ma mcv.
stfcn.i%try w.wersng
OREMAT101MONTN.NEftt'VR11
el.se 0:y r cv c'kr f,%:Ov%vY;1
An urn to tan tested as a cunt t i(v for the cfcmated wmi ns has Wen prehased tram
and iti&-W40d SS 10`.OA-V
Me w4crstlnd thit d thL tyn is too srma7 to lwdd vic crttre cremated rcrs+.tns.an add tool rqd cotaner may be
v►ed for Cr+ivcry.
•OR-
�'-, M urn has rtct Yct Dccn perchasra I.A`;e undc�fsMrid that 0 no tern N.pwcMscd or Other-wow rifOV ded
f:.w•��I�'w�► Pir1Q ViC�N Cr�m.Z'tx�► ..,�n:t psxc ts,r:uemztcd ww'ns in a rogd tcv�porary
� COr+:.7stCr f0f dCt+vcty.
Ttrs AtAhwi aton fcvm was prov4cd by ro vw avv,*.,^h**t Ro!Und G. ifo.�
woe�ereeutcd at r. xh�*••+.•++t_...e..� CQmp;trgrs:l•.t? Fur�crll C��C.,trtC
r�J+MM+.*M«a►.++)�Q2 I.L�,Ib/"iV�3.,�§•?ri1;o. 1 sjSclll(ts,NY 12$6_and n.•.xjncd by tho funernt C IcCW
M.lMitlCSS to as exctte'Cn.
t.ele ha-.r rccctvcd a corVctcd Copy d Uvs Autrtonla-.*n Form
The perso (s)Identified below islare the person(%)in control of disposklom who by signing this
Authorization Fom attest(s)to the accutacy and completeness of dw Infortution contained In this
Authorization Form and auVwlse(s)the foregoing.
Signed this Sth day of &V
Eati K.Stmad
frW a 01 llkr PSA-V Jr
3 HaWand Orivo.Gkiwi"a.NY 12302
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Evelyn 1.1.1otso
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