Schramm, Edward G. Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
vc FUNERAL HOME: F ldcd Vy,. Cuv,,&<&
REQUESTED RETURN TIME:
►_ NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
1 ivt 01,herMolr.
qL NAME: Dln AI( b CSC N k A YAM CASE # �SLO
DATE OF CREMATION: 9-16-zaz n
TIME STARTED: /!) _ TIME COMPLETED: Z
TYPE OF CONTAINER: HJebb R?_Av (c, '(6 > - 60T72)m
CP-EXAPI-06Z (20 r<sd.
0
PLACED IN RETORT: jD` ._ MOVED:
*- PLACE OF DEATH: ( rjJ
ESTIMATED WEIGHT OF REMAINS AND CONTAINER: 1��
k DATE & TIME REMAINS ARRIVED AT CREMATORY:
PLACED IN HOLD: Lon
PLACED IN REFRIGERATION:
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.
x1cuSsgn Envelope ID:68F02389-AE1D-4E48-A9135-E011C4312F4E
New York State
NYEWYORK DIVIS10110f DIVISION
of Stet e
STATE OF ON OF CEMETERIES
One Commerce Plaza
OPPORTUNITY. Cemeteries 99 Washington Avenue
Albany,NY 12231-0001
Telephone:(518)474-6226
Authorization for Cremation and Disposition www.dos.ny.gov
This Authorization Form must be completed and signed prior to delivery of remi tins for cremation.
Date:-04/13/2020 3
Number.
Crematory Name: Pine View Cemetery &Crematorium
Address: 21 Quaker Rd, Queensbury Hamlet, NY 12804 Phone: 18 745-4476
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation is carried out by placing the remains of the deceased and the container holding the remain s into a cremation chamber where
they are subjected to intense heat and flame. The heat and flame will incinerate and consume ev WYthing 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 in 'dental 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 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 holding the un-cremated human remains in limited clrcum stances,such as to confirm the
identity of the deceased or to ensure that no material is enclosed which might injure employees or dar iage 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 ft 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: Edward G. Schramm Mi rital Status: Widowed
Last Known Address: 38 Ivanhoe Drive, Merrick NY 11566
Place of Death: Meadowbrook Care Center, 320 West Merrick Road, Freeport, NY 11 20
Sex: ®M OF Age: 94 DOB: 11/06/1925 Date of Death: 04/10/2020 Estimated Weight: —7)
Description of casket/container in which remains will
delivered.
Cremation Container Gt/ti (0►_v 4 ' S rc� �4PG
PERSON IN CONTROL OF DISPOSITION
(Person(s)in contro/of disposition, inkial ONE of the following)
P--.S I amble are the designated agent of the deceased designated in a will or written instrumai t executed pursuant to Public
Health Law Section 4201.
-OR-
INVe have no knowledge that the deceased executed a written instrument pursuant to Pub c 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 prio ity under Public Health Law
Section 4201 and have the right to authorize cremation of the remains of the deceased. My/Our relatI4 nship to the deceased Is as
follows:
Edward G. Schramm
meme of DO mwd)
DOS-18984(Rev. 08/15) Page 1 of 3
7ocu:3ign Envelope ID:B8F02389-AE1D-4E48-A9D5-E011C4312F4E
Authorization for Cremation and Disposition
(Insert from the list below)
Number: 3 Description:son
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 clo t in relationship to the deceased;
6. A duly appointed fiduciary of the estate;
9. A close friend or relative who has executed a written statement pursuant to Public Health Law 3ection 4201(7);
10. A chief fiscal officer of a county or a public administrator appointed pursuant to the Surrogate's Court Procedure Act;
10& Any other person who is acting on behalf of the deceased and who has executed a written stat ment pursuant to Public Health
Law Section 4201(7).
(Initial ALL THREE of the following)
I/We hereby affirm that the body of the deceased does not contain a battery,battery
ry pacK power cell, radioactive implant,
or,radioactive device and that any such materials were removed prior to the execution of this Authorl adon Form. Failure to remove
these items prior to cremation may result in harm to the crematory and crematory personnel.
IMe affirm that instructions have been given to James F. G vl an
(FuneralDkocbr j
regarding the removal of any personal property or other thing of value which any person signing belovi or any family member of the
deceased wishes to preserve. Pine View Cemetery & Cremato m
is not responsible for the removal of (C—J-yAA-e)
Po personal items from the container or from the remains of the d sed. Personal Items left In the
container or with the remains will be destroyed by the cremation process and cannot be ret ie after cremation.
'PS Me hereby authorize Pine View Cemetery &Cremat rium
(crarlmy fie)
to cremate the remains of the deceased.
FINAL DISPOSITION
The person authorized to receive the cremated remains of the deceased from the crematory is:
Name: N. F. Walker, Inc., James F. Gavigan
Address: 2039 Merrick Avenue, Merrick, NY 11566-3434 Phone: (5 6) 378-0303
The cremated remains of deceased will be disposed of as follows:
To be decided
If for any reason the person named above does not take possession of the cremated remains,
Pine View Cemetery &Crematorium is authorized to give possession of
(C—lbry Ara—)
the remains to N. F. Walker, Inc.
(Fwwall�am Nam) by delivery
in person or by registered mail.
Edward G. S hramm
(A%rm of Dacm ad)
DOS-1898-f(Rev.08115) Page 2 of 3
Docu&ign Envelope ID:B8F02389-AElD-4E48-A9D5-E011C4312F4E
Authorization for Cremation and Disposition
(initial the following)
�S I/We understand that if the remains are not claimed within 120 days of cremation,
Pine View Cemetery & Crematorium ay dispose of the remains in
an irretrievable manner,such as by scattering. (Namawcremafty)
CREMATION CONTAINERIURN
Initial ONE of the following)
An um to be used as a container for the cremated remains has been purchased from N. F. Walker Inc.
and is described as follows:
Me understand that if the urn is too small to hold the entire cremated remains, an additional rigid coi twiner may be used for delivery.
-OR-
�s An um is not yet purchased. IM/e understand that if no urn is purchased or otherwise jpxr, 'ded
Pine View Cemetery&Crematorium 11 place the cremated remains in
(NMM ofCrenrtory)
a rigid temporary container for delivery.
This Authorization Form was provided by James F. Gavl an was executed at
(Fun"Dieda►Name)
N. F. Walker, Inc.
(FwmW None Name)
2039 Merrick Avenue, Merrick, NY 11566-3434
(Funeral None Address)
and is signed by the funeral director as witness to its execution.
IM/e have received a completed copy of this Authorization Form.
The person(s)identified below isiare the person(s)in control of disposition,who by signing Mill Authorization Form,attest(s)
to the accuracy and completeness of the Information contained in this Authorization Form and uthorize(s)the foregoing.
Signed this 13th day of April ,y0 20
Peter Schramm
Typed ar PrbMad Name
38 Ivanhoe Drive, Merrick„ NY 11566-
yped cr
Typed or Ffmosd News SipnaMee
Aftew
WITNESS:
James F. Gavigan
(Funanl D.ado.Typed or A* Name) IFIT Dkedw slcn wa) PA
11320
Edward G. Schramm
(Name afDec memo
DOS-1898-f(Rev.08/15) Page 3 of 3