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Burton, James W. Pine View Cemetery & Crematorium Quaker Road Queensbury, NY 12804 (518) 745-4477 or (518) 745-4476 FUNERAL HOME: N7 REQUESTED RETURN TIME: NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS: NAME: 30 DATE OF CREMATION: TIME STARTED: I):as A t') -- ---------- 1_► -------TIME COMPLETED: -------�SO ?h — TYPE OF CONTAINER: ------- W i kL Uoe ---- PLACED IN RETORT: ___ 15 h MOVED: PLACE OF DEATH: -------- ESTIMATED WEIGHT OF REMAINS AND CONTAINER: DATE & TIME REMAINS ARRIVED AT CREMATORY: _ �70 g:00 d ll PLACED IN HOLD: PLACED IN REFRIGERATION: p 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. t New York State State NEW YORK nsla of cl*11=Trtment�ERIEs STATE OF Division of tm One Commerce Plaza OflPODUNITY. Cemeteries 99 Washington Avenue Albany,NY 12231-0001 Telephone:(518)474-6226 www.dos.ny.gov Authorization for Cremation and Disposition This Authorization Form must be completed and signed prior to delivery of remains for cremation. Date: 4/3/2020 Number. 301 Crematory Name: Pine View Crematory Quaker Road,Queensbury,NY 12804 518-745-4477 Address: Phone: CREMATION IS AN IRREVERSIBLE AND 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 subjected to intense heat and flame. The heat and flame will incinerate and consume everything except tone 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 mechanically pulverized into small pieces and placed into a designated container or um. 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 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 the crematory property. 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 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 respell. IDENTIFICATION OF DECEASED James W. Burton Married Name of Deceased: Marital Status: Last Known Address: 3 Boulevard St., Hudson Falls, NY 12839 Place of Death: Glens Falls Hospital, Glens Falls, NY 12801 75 10/20/1944 4/3/2020 j Sex: ®M ©F Age: DOB: Date of Death: Estimated weight: Description of casket/container in which remains Will be delivered. MacDonald Container;basic cremation container with wood reinforced bottom PERSON IN CONTROL OF DISPOSITION (Person(s)in control of disposition,initial ONE of the folknving) I am/We are the designated agent of the deceased designated in a will or written instrument executed pursuant to Public Health Law Section 4201. -OR- I/We 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 I/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. MylOur relationship to the deceased Is as follows: James W. Burton (Nerve dnece&"w DOS-1898-f(Rev.08/15) Page 1 of 3 Authorization for Cremation and Disposition (Insert from the list below) Number. 2 Description: Spouse 1. A person designated in writing pursuant 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 older; 6. A lawfully appointed guardian; 7. Any person(s)eighteen years of age or older entitled to share in the estate and who is/are closest in relationship to the deceased; 8. A duly appointed fiduciary of the estate; 9. A dose fiend or relative who has executed a written statement pursuant to Public Health Law Section 4201(7); 10. A chief fiscal officer of a county or a public administrator appointed pursuant to the Surrogate's Court Procedure Ad; 10a. Any other person who is acting on behalf of the deceased and who has executed a written statement pursuant to Public Health Law Section 4201(7). to&l ALL THREE of the following) - .1)B—I/We hereby affirm that the body of the deceased does 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. Patricia Miller I I/We affirm that instructions have been given to (Fwwral t);nedor Name) regarding the removal of any personal property or other thing of value which any person signing below or any family member of the Pine View Crematory deceased wishes to preserve. (oremebay Nerve) is not responsible for the 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. Pine View Crematory _W uwe hereby authorize (GemeEory Name) to cremate the remains of the deceased. FINAL DISPOSITION The person authorized to receive the cremated remains of the deceased from the crematory is: Miller Funeral Home Name: 6357 NYS Rte.30,Indian Lake,NY 12842 518-648-0011 Address: Phone: The cremated remains of deceased will be disposed of as follows: burial in Cedar River Cemetery, Indian Lake If for any reason the person named above does not take possession of the cremated remains, Pine View Crematory is authorized to give possession of (G.mabar Nerve) the remains to Miller Funeral Home by delivery (Furw W Nana Name) -in person or by registered mail. James W. Burton (N&-M wvece"80 DOS-1898-f(Rev.08/15) Page 2 of 3 Authorization for Cremation and Disposition (La ' /the following) 00 Me understand that if the remains are not claimed within 120 days of cremation, Pine View Crematory may dispose of the remains in (Name of Crenaby) an irretrievable manner,such as by scattering. CREMATION CONTAINERAJRN (l_,r a ONE of the following) An um 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 um is too small to hold the entire cremated remains,an additional rigid container may be used for delivery. -OR- 3 An um is not yet purchased. INYe understand that if no um is purchased or otherwise provided Pine View Crematory will place the cremated remains in (Mere of Carr o-A a rigid temporary container for delivery. This Autirod Patricia Miller zation Form was provided by was executed at (FinarN Uieaw Mum) Miller Funeral Home 6357 NYS Rte.30,Indian Lake,NY 12842 (Fww*Home Nana) (FWWW Home Address) and is signed by the funeral director as witness to its execution. I/We have received a completed copy of this Authorization Form. The person(s)IdentEW below Islare the person(s)In control of disposition,who by signing this Audwdzedon Form,attest(s) to the accuracy and completeness of the Information contained In this Authorization Form and auttwrize(s)the foregoing. Signed this 3 day of April ,20 20 Donna Burton kin A Typed orPhnW Name 3 Boulevard St.,Hudson Falls,NY 12839 Addmn TypW or P*"Name TypW or P*ad Name S` e Adders WITNESS: Patricia Miller �(1J (Funeral DiecW Ty W or P"Pftd Name) (Funeral Director SVMO—) 12465 James W. Burton (Name o/DacwaW) DOS-1898-f(Rev.08/15) Page 3 of 3