Gallipoli, Linda 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:
NAME: ------------------ -- ----CASE # -----
DATE OF CREMATION:TIME STARTED: OS
------.--_..-- _------.---------TIME COMPLETED: ��
TYPE OF CONTAINER: -P12—re
-------------------------------------------------------------------------------------
PLACED IN RETORT: _
---------___._-----------MOVED-
PLACE OF DEATH: �QZ�, /� -
ESTIMATED WEIGHT OF REMAINS AND CONTAINER: 7Sjs
DATE & TIME REMAINS ARRIVED AT CREMATORY: �a - 3�G--zoZ6
PLACED IN HOLD: --
PLACED IN REFRIGERATION:
RETORT # IN WHICH REMAINS WERE
DETAILED REASON 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 York State
NEW YORK Department of state
Di vision of DIVISION OF CEMETERIES
STATE OF One Commerce Plaza
OPPORTUNITY_ Cemeteries 99 Washington Avenue
Albany,NY 12231-0001
Telephone:(518)474-6226
www.dos.ny.gov
Authorization for Cremation and Disposition
This Authorizadon Form must be completed and signed prior to delivery of remains for cremation.
Date. 1'IG'�GV1 J. 101�!i Number.
Crematory Name:Pine View`Crematory
Address: vo.Kx5z- Phone: `s�56' �1 1 Lk":3- qq 1
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 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)eft 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 respect
IDENTIFICATION OF DECEASED \ \
Name of Deceased: (I ',,r\ �o, �G�c`��'�0`� Marital Statu �►s: 1-�cw�e,\,4-
Last Known Address: 1 ot. �J.J, �1b.111t- A V'sp-1�\C�--X� 0<1 , �)y \ S
Place of Death: • �j . �v - O �^ \ v
Sex: ❑M 19 F Age: J 1) DOB: 0 �5 ��(o I Date of Death: C)3 �� Estimated Weight: �"J
Description of caskeYcontainer in which remains will be delivered.
PERSON IN CONTROL OF DISPOSITION
(Person(s)in control of disposition,initial ONE of the following)
I amNVe are the designated agent of the deceased designated in a will or written instrument executed pursuant to Public
Health Law Section 4201.
-OR
IP 6- 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 Uwe 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. My/Our relationship to the deceased is as
follows:
(Naw ar
DOS-1898-f(Rev.OS/1 5) Page 1 of 3
Authodzadon for Cremation and Disposition
(Irrsertllvm ttt atmow)
Nhunber__l__ DnWpo=
(Z, The in Ong to public Heetfh Law Sermon 4201(3);
��a.. The surer M domestic parbw.
3. Any shxvM%chid eighteen yews of age or older;
4. A suNmtig parent;
8. A surviving sibling eWftm yms of age or older.
B. A lewtully appokil ed guardian;
7. Any person(s)eighteen years of age or older entitled to dwe in fie estate and who isfare closest in relationship to the deceaset
L A duly appointed fldtxlary of the esstgW
9. A close Mend or relative who has exectited a wrlen Oblemert:purshmnt to Public Haab Law Seen 4201(7};
10. A chief fiscal onicer of a county or a pubic Ddn**WuADrapperr"d purscmnt ro ilia Sunogate's Court Procedure Act
10a. Any other person who is acting on b;h&of the deceased and who has executed a w fin ntatement pummnt to Public Health
Law Section 4201(7)_
(lrh&I ALL THREE of the following}
's.�—Me hffeby alTum that the body of the deck does not corftin a fir.battery pads,pmw can,radoadve implant
or radioacli ee device and VW any such mal erh is were removed prior to the exec tMon of this AufhothWon Form. Failure to remove
Own items prior to craw afion may result in harm to the crematory and crematory personnel.i/We affirm that moons have been groan to K,\e-- i�\ Mq�`
AkdWAu W
n gating the removal of any personal property or otlwr flung of vakie which any person sig"below or any family member of the
deceased wishes to preserve. PMG View Crematory
is not responsible for the removal of n
presonat iterr>s from the confainw or from the remains of the deceased. Personal(terns left in the
contalner or with the remains will be deatWed by the croon process and cannot be retrieved aff er creneatt m
I/We hereby auduirb a Pine view Crematory
to cremate the rernalrw offfle deceased.
FINAL 2ISPOt31=
The person autltortmd to receive the created remains of the deceased from the crematory is:
Name:Any Staff from the Edward L Kelly Funeral!-lame
Address:1019 US Rt 9 PO Box 548,Sdhroon Lak-,W 12870 Phone:518532 7177
The cremated remains Of deed will be -of as fry-.
If for any reason the parson named above does not We possession of the cremated remains,
Plne view Crematory is audxxt ed to 9n possession of
rcamroo.u- a
the remains to Edward L K*Fur"Home by delivery
in person or by registered mail.
(Me�dQeosa�ap
DOSAM4(Rev.08115) Page 2 of 3
Authorization for Cremation and Disposition
Inmet M ng)/e fwowi
-�-�_I/We understand that if the remains are not claimed within 120 days of cremation,
Pine View Crematory
eftwmay dispose of the remains in
an irretrievable manner,such as by scattering. � �
CRENATION CONTAINER/URN
(laft ONE of Me following)
An um to be used as a container for the cremated remains has been purchased from Edward L Kelly Funeral Home
and is described as follows:
UWe understand ttrat if the um is too small to hold the entire cremated remains,an additional rigid container may be used for delivery.
-OR-
,An um is not yet purchased_ I/We understand that if no um is purchased or otherwise provided
\� CK��� �� will place the cremated remains in
cx�,aorcrJ
a rigid temporary container for delivery. \
This Author&Won Form was provided by �� `�� was executed at
rFunera�O�isUorniarne)
Edward L Kelly Funeral Home
1019 US Rt.9,PO Box 548 Schroon Lake,NY 12870 rVWW
(Firreral H—Ad&—)
and is Signed by the funeral director as witness to its execution.
I/We have received a completed copy of this Author&nfion Form.
The Person(s)identified below Ware the person(s)In control of deposition,who by signing this Ausnarhadon Form,attest(s)
to the accuracy and completeness of the information contained in this Authorization Form and authorize(s)the foregoing.
Signed this _day of �Acq ,20 tJ
TnwdrpftwAf�e
l�. q ofie.
TYPed orPriMed Alame
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WITN S:
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DOS-1898-f(Rev.08115) Page 3 of 3