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Jones, Roger E. Pine View Cemetery & Crematorium Quaker Road Queensbury, NY 12804 (518) 745-4477 or (518) 745-4476 FUNERAL HOME: _ AWROLCL - - REQUESTED RETURN TIME: NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS: NAME: _-CASE # q ------------- -------_DATE OF OF CREMATION: ��I to TIME STARTED: Zop ---------i h ---------TIME COMPLETED: --------3-=��- TYPE OF CONTAINER: w__. PLACED IN RETORT: ----.._.__...---------�-�-----------MOVED: - z,.Zv JO PLACE OF DEATH: ESTIMATED WEIGHT OF REMAINS AND CONTAINER: -------------- DATE & TIME REMAINS ARRIVED AT CREMATORY: .______ PLACED IN HOLD: PLACED IN REFRIGERATION: r2_`�0 RETORT # IN WHICH REMAINS WERE CREMATED: 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. New Y0*$sxe NEYi/Y�K �af� Do 'Si©n of 1XVI�N OF Clams STATE OP Orte Commerce Ple2a O[?pORftlNlilf. Cemeteries Albany,W W31-00t Telephone kS18)47"226 www.doS,ny.gov AuthodzaWn for Cremation and Disposition This Audmiza6m Form wrest be compiled curd signed prior to delh+ery Of remains fOr cxmnad4i " Date:03J3012020 Number. Crematory Name: Pine View CremaWry Addmw 21 Quaker Rd.,Queensbury, NY 12804 Phone: CREMATION IS AN IRREVERSIBLE AND FINAL PIK)C€SS. Cremation is canted out by placing the remains of the did and the container holding the remains into a cremation ciUWM*r where they are subjecled to intense heat and flame The heat and flan*will incinerate and consume everythbW accept bone and rastal, which are all that will be Wdt a ftr cremation. Fallowing crematim the cremalory will take reasona Me efforU to remove all of the remains and other material from the cremalon chamber,but some ffftnal dust and residule will Illmly be left bW*A The cremaUnyt will separate incideoW and foreign material from the remains and lice kvddeintel and 110(*n materiel vA be disposed of as required by Law. The cremated remains will be mechanically pulverized into email pieces ad Placed into a designated container or urn: Cremated remains generdlly am Pulverized WO 20 single fragment is recognizable as skeletal tissue. 0PE11lI"%0F TIDE COfhtTAINFR The crematory mW only open e container holding the un-cremalasi human remains in limited circurnstasnow,such as to=Arm the klenlgy of the deceased or to Omura that r*material is en d which MIgM iqufe,erenplayees or dw*W ithe aemMXy pKpertY- If human remains are delivered in a container which is not suitable for arennation such as c ommonia l or rental caskek fire crenwAory hwili require that the remains be nand loW a suitable eootainer before fR aehxpts the remain`. The opernint of a container or the transfer or removal of remains*AN be conducted before a witness and will be done in privacy,with dgrAY and respect. IDENTIFICATION OF DECEASED Name of Deceased: Ruler E.Jones Marital Status: Married Lost Kwom Addgew 3468 State Route 8 Johnsburg, New York 12843 Place of Doh: Glens Falls H2NM, 102 Park Street, Glens Falls NY 12801 Sex: 0 M D F Age. 89 DOS; 09/27/1930 DOW of Deaft 03(28/2020 Iwmated weight: 160 Description of easlce*ontainer in which remains will be delivered. New England Cremation deluxe container PERSON IN CONTROL OF DISPOSITION (pWZo1AV on conborof dvpo&ftn, OIVIr of UM Wbwfg) I amNVe are the designated agent of the demawd d"U natsd In a will or writtwn k0tru""t eXectrW Pcnsuent to POW0 Hmkh Lahti Seder 4201. -OR X IANe have no knowledge that fire deceased exe*Aed a awilten im$trUment pursuant to PubiW Health Lev Section 4201 are wlq containing directions for the disposition of his or her rarrtdm and Ito*are the person(s)having priority ender Public Heath Law Section 4201 and have the right do authorize cremation of the remains of the deceased. MylOur relartionshrp too the doused Is as follows: ROT E.Jules DOS-1t3W(Rev,O13MS) Page 1 of 3 Authorization for Cremation and Disposition (insert tam me Osstbebw) Nunnber. 3 oescription:SurvMpRshild 1. A person designated in vAng pursuant to Public Health Law Section 4201(3); 2. The surviving spouse: 2a. The surviving dameslic padner, 3. Any surviving child eighbm years of age or older, 4 A surviving parent; I A surviving Wing eighteen years of age or older. & A lawMy appointed guardian; 7. Any pem0n(s)G~Yews of age or older entitled W share in the estate and who Ware closest in relationship to the dew & A duly appointed fiduciary of the estate; 9 A close fiend or relative who has executed a written statement pursuant to Public Health taw Section 4201(7'); 10. A chief Iscal WOW Of a county or a pubic administrator appointed pursuant to the Surrogates Corot Procedure Act; 10a. LAny other Section rson is adkV on behalf of the deceased and who tM executed a written statement pursuant to Public Health (kAWAAU THREE of fire fcllow*W �'!Rk Me hereby affirm that the body of the deceased does not contain a be". r p ,power bell,nx iosctive implant: or radaoaclive device and that any such materials were removed prior to the Oncwtion of this AeWw#f=Won Farm. Failure to remove these items prior to cremation may result in harts to the crematimy and crematM persmael. Me affirm that instructions have been given to David Alexander regarding the removal of any personal property or other thing of value which any person signing below or any family member of the deceased wishes to preserve. Pine View Crematory is not responsible for the rernoval of personal item from the ernrneairrer or from the remains of the deceased. Personal items Heft in the container or wNh the remains will be destroyed by the:creivation prabess MW cannot be retrieved after tiamatiorr. X 1W Me hereby mithorize Pine View Crematory (O-.kVyN4Nv to cremate the remains of the deceased. FINAL DISPOSITION The person authorized to receive the cremated remains of the dec om;W from the crematory is: Name:Alexander-Baker Funeral Home,David Alexander q,d#ess; 3809 Main Street,Warrensburg, New York 128M phom: (518)623-2065 The cremated remains of dosed will be imposed of as follows: Retum to family If for any reason the pewn rained above does fiat take possession of the cremated remains, Pine View Crematory is authorized to give possession of rc-n bry+h—1 the remains to Alexander-Baker Funeral Home by delivery i )4XM@AWFW in person or by registered mail. Roger E. Jones O"'Maraia w"O DOS-1898-t(Rev.OSf15) Page 2 of 3 AuthodzsUon for Cron and Disposition MO�ftkftmv) X Ml"UWe understand that if the remains are not daimed vyithin 120 days of crsrnatian, Pine View Crematory may dispose of the remains in rQft an irretrievable manner,such as by scattering. CREMATION CONTAMI MURN (initial ONE of the Alexander-Baker Funeral An urn to be used as a conftlh u'for the cremated remains has been purchased from uewma and is described as kilows: INVe understand to if the earn is too small to hold to ere M cremated remains.an WOO"rigid oonmainer may be Lved for delivery. 0' —An urn is not yet p xchased. JAMe undersand"if no urn is pumhaaed cx othervA60 procrided Pine View Crematory will place the cremated remains in a rind temporary container for delivery. This Arabori aSm Form was provided by David Alexander was executed at Alexander-Baker Funeral Home sb3809 Maw steetWerurg, New York 12885 nrrrM., a and is signed by the funeral d►redor as Witrim to its execution. Wife have received a ecreepided copy of this Auffwdzaftn Fotim- T"W persons)identified below jwme the pwsan(s)in control of disposition.wha b!I U90M tlds Acrtlror"rtion farm.anest(s) to the accuracy MW co- ple. of the information contained in this Aumovizaliorr Farm and auiborise(s)the toregolkrg.. signed the 30th__.. day of March p 20 20 - Rita L Randall 1917 Calf St., Lake Luzeme, NY 12846 a AdOWS a N�r+a Sa�R+�s tfiU1'NFrSS: David Alexander (FaMst�w�xrypaeaArurranwne) �` 10034 Roger E.Jones DOS-1898_f(Rev.©SM 5) Page 3 of 3