Lavery, John 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:
DATE OF CREMATION:
TIME STARTED:
COMPLETED:
TYPE OF CONTAINER:
PLACED IN RETORT: ''3p AA-
-I ------- ---------------- __-.__MOVED ___
PLACE OF DEATH;
,At_.----,
ESTIMATED WEIGHT OF REMAINS AND CONTAINER:
DATE & TIME REMAINS ARRIVED AT CREMATORY: AA-
PLACED IN HOLD:
PLACED IN REFRIGERATION:
RETORT # IN WHICH REMAINS WERE CREMATED: kv.
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.
v
New York State
Department of State
NEW YORK DIVISION OF CEMETERIES
�dF Division of
OPPORTUNITY. t?ns Cwnmerca Wa=a
r—fCemeteries 99 Washington Avenue
Albany,NY 12 2 31-00 01
Telephone:(518)474-6226
www.fts.ny.gov
Authorization for Cremation and Disposition
This Authorization Form must be completed and signed prior to delivery of remains for cremation.
Date: 04/10/2020 Number: Z
Crematory Name: Pine View Crematorium
Address: 51 Quaker Road, Queensbury, NY 12804 Phone: (518)745-4477
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 wilt 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 urn. Cremated remains generally are pulverized until no
single fragment is recognizable as skeletal tissue.
OPENING OF THE CONTAINER
The cravwtary may only open tha container holding the un-cremated human remsum in rtmded c ucumstances,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: John Lacey Marital Status: Divorced
Last Known Address: 152 Sherman Ave, Queensbury, NY 12804
Place of Death: Glens Falls Center, 152 Sherman Ave, Queensbury, NY 12804
Sex: ®M OF Age: 70 DOB: 03/18/1950 Date of Death: 04/10/2020 Estimated Weight
Description of casket/container in which remains will be delivered. �11
PERSON IN CONTROL OF DISPOSITION
(P (s)in control of disposition,initial ONE of the following)
.�
}affvWe are the designated agent of the deceased designated in a will or written Instrument executed pursuant to Public
Health Law Section 4201.
-OR-
INVe 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 Low
Section 4201 and have the right to authorize cremation of the remains of the deceased. My/Our relationship to the deceased is as
follows:
John Lavery
OAwmo(Doommd)
DOS-18Wf(Rev.08/15) Page 1 of 3
v
Authorization for Cremation and Disposition
(Insert from the list below)
Number: 5 Description: Brother/Agent
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 close friend or relative who has executed a written statement pursuant to Public Health Law Section 4201(7);
10. A chief fiscal officer of a county of a public administrator appointed pursuant to the&wagate's Court Procedure Act;
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).
India/ALL THREE of the following)
10 Me 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 ware removed prior to the execution of this Augwrtzablon form. Firth"to remove
these items prior to cremation may result in harm to the crematory and crematory personnel.
M!Me affirm that instructions have been given to Wendy M. Bulich
r
regarding the removal of any personal p►gmfty or other thing of value which any person eVm#t below or any family member of the
deceased wishes to preserve. Pine View Crematorium
(rY
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.
YVe hereby authorize Pine View Crematorium
to cremate the remains of the deceased.
FINAL DISPOSITION
The person authorized to receive the cremated refrains of the deceased from the crematory is:
Name: Regan Denny Stafford Funeral Home
Address: 53 Quaker Road, Queensbury, NY 12804 Phone: (518)792-1114
The cremated remains of deceased will be disposed of as follows:
Burial—Pine View Cemetery
If for any reason the person named above does not take possession of the cremated remains,
Pine View Crematorium is authorized to give possession of
ITO-NA"
the remains to Regan Denny Stafford Funeral Home by delivery
(Funeral Horne Name)
in person or by registered mail.
John Lavery
(Name or Deceased)
fst1S-i$98-#(Ftev 08it 5) Page 2 of 3
Authorization for Cremation and Disposition
(Inrfi 1 the following)
INVe understand that if the remains are not claimed within 120 days of cremation,
Pine View Crematorium may dispose of the remains in
(Nerve d crrnrtny)
an irretrievable manner,such as by scattering.
CREMATION CONTAINER/URN
(Initial 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:
Me understand that if the urn is too small to hold the entire cremated remains,an additional rigid container may be used for delivery.
O
An urn is not yet purchased. INVe understand that if no urn is purchased or otherwise provided
Pine View Crematorium WW place the crerneted remelns in
(Name c/Cremshry)
a rigid temporary container for delivery.
This Authorization Form was provided by Wendy M. Bulich was executed at
(F--W D-Ow Name)
Regan Denny Stafford Funeral Home
(reff-W hb-Name)
53 Quaker Road, Queensbury, NY 12804
Vinre)HbmeAd kvM)
and is signed by the funeral director as witness to its execution.
Me have received a completed copy of this Authorization Form.
The person(s)Identified below Is/are the person(s)In control of disposition,who by signing this Authorization Form,attest(s)
to the accuracy and completeness of the information contained in this Authorization Form and authorize(s)the foregoing.
Signed this 11 th day of April ,yp it20
— ,4- 1a U-1 rv"-
Herbert Lavery
Typed a PnrAW Name
90 Waldetf Way, Mr94CWd,MA 01M-
Typed or _
Addnms
Typed or Phrrkd Nana
Address
WITNESS:
Wendy M. Bulich f U
rFW&af Gkw.4 r Typed o°PYaded Name, L"'"Di[MI Si' nr
10441
John Lavery
(Name ofDecsssed)
DOS-1898-f(Rev.08/15) Page 3 of 3