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Driscoll, Joseph James Pine View Cemetery & Crematorium Quaker Road Queensbury, NY 12804 (518) 745-4477 or (518) 745-4476 FUNERAL HOME: �DaCe� tig� REQUESTED RETURN TIME: ......_-_._- SfP .. NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS: \/IC -�-A,4,10 NAME- -.- CASE tt DATE OF CREMATION: Zvi TIME STARTED; foo �+^ QQ-- - TIME COMPLETED: - �7 ✓1'1 TYPE OF CONTAINER: V _ f'If�7�D� PLACED IN RETORT: �06 MOVED: PLACE OF ESTIMATED WEIGHT OF REMAINS AND CONTAINER: DATE & TIME REMAINS ARRIVED AT CREMATORY: PLACED IN HOLD: _._------------ --- --- - 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 13E RETAINED IN THE PERMANENT FILE OF THE CREMATORY Authorization for Cremation and Disposition l NYS Department of state One Commerce Plaza,99 Washington Avenes nue Albany,NY 12231 (518)474.6226 —dossl.us This Authorization Form must be completed and signed prior to delivery of remains for cremation. Date: 04/17/20 Number Crematory Name: Pine View Crematory Address: 21 Raker Road_Q_. —Queensbury NY 12804 Phone: (518)745-4476 _ [Following REMATION IS AN IRREVERSIBLE AND FINAL PROCESS. -- remation is carried out by placing the remains of the deceased and the container holding the remains into a emation chamber where they are subjected to intense heat and flame.The heat and flame will incinerate and nsume everything except bone and metal,which are all that will be left after cremation. cremation,the crematory will take reasonable efforts to remove all of the remains and other material from e 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 CONTAINER. _I 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 crematory property.If human remains are delivered in a container which is not suitable for cremation such as a 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: Joseph James Driscoll - _ Marital Status: Never Married Last Known Address: 25-43 42nd Sheet Bsmt.Apt.,Astoria NY 11103 Place of Death: 25-43 42nd Street Bsmt.Apt. Astoria,NY 11103 Sex: 0M ❑F Age: 58 DOB: 1 2/1 411 96 1 Date of Death: 4/10/2020 Estimated Weight. �.S Description of casket/container in which remains will be delivered: Wood cardboard cremation container PERSON IN CONTROL OF DISPOSITION (Person(s)in control ofdisposdion,i iti ONE of the following) 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. ' Lam_ I/We have no knowledge that the deceased executed a written instrument pursuant to Public Health Law ection 4201 or a will containing directions for the disposition of his or her remains and (C-timed nextpage) lose_ h James Driscoll DOS-1896-t-I(Rev.01/t 0) Name of Daoaased Page 1 of 3 7 6 1 am/we are the person(s)having priority under Public Health Law section 4201 and have the right to authorize ( d J cremation of the remains of the deceased. My/Our relationship to the deceased is as follows: (Insert from the list below) Number:__5 Description: A surviving sibling eighteen years of age or older _ 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; S.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; 8.A close friend or relative who has executed a written statement pursuant to Public Health Law§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§4201(7) (/ i I ALL THREE of the following) �tf� y 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 gmmatory personnel. I/We hereby affirm that instructions have been given to(hneratdire torname) Thaddeus W.Baxter _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.(—etoryneme)__ Pine View Cremator _is not responsible for 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. OWI IIWO hereby authorize(aematoryname)_ _Pine View Cremato mains of the deceased. - �_.__to cremate the FINAL DISPOSITION The person authorized to receive the cremated remains of the deceased from the crematory is: Name: Fox Funeral Home Inc Address: 98-07 Ascan Avenu�Forest Hills,NY 11375 (718)268- Phone: 771](507)675 61gi The cremated remains of deceased will be disposed of as follows: Yet to be determined If for an reason the Y person named above does not take possession of the cremated remains, (cremerory came) Pine View Crematory __is authorized to give possession of the remains to rfuee at tome neural Fox Funeral Home Inc.__by delivery in-- ry person or by registered mail. Joseph James Driscoll DOS-f e98-4i(Rev.07i10) Name o/Dec esed Page 2 of 3 8 /(lnii]6.-II thhe fo/towing) ( 7 ) �i.�,�Ze understand that if the remains are not claimed within 120 days of cremation, (/ wemarory name)_- Pine View Crematory may dispose of the remains in an irretrievable manner, such as by scattering. CREMATION CONTAIN o/uwu (lnitla/ONE of the following) An urn to be used as a container for the cremated remains has been purchased from Fox Funeral Home,Inc. and is described as follows: UWe understand that 1f the urn is too small to hold the entire cremated remains,an additional rigid container maybe used for delivery. NAn urn has not yet been purchased. Ilwe understand that if no urn is purchased or otherwise provided ame) Pine View Crematory will place the cremated remains in a rigid temporary container for delivery. The Authorization Form was provided by Ir erald vw,,,e)_ Thaddeus R'.Baxter was executed at)tunes)home name) Fox Funeral Home,Inc. _ ltwerai home addn,ea) 98-07 Ascan Avenue,Forest Hills,NY 11375 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)Identified below isiam the persona)in control of disposition,who by signing this Authorization Form,sttest(s)to the accuracy and completeness of the information contained in this Authorization Form and authorize(s)the foregoing. Signed this 17th day of_- April 2 Zp Joan Marie Driscoll � "Vw'or Printetl Name 1409 Audubon Parkway,Louisville,KY 40213 signatu Address Typed wPnntetl Neme --.— Address - --- TY- Printed Name _ Signature --- -- Address _- WITNESS: Thaddeus W.Baxter Furre2l Direcfw Typed o/PnMetl Name Fwrerel Dimctw Signatum 10227 _ Repisballon Number Joseph James Driscoll DOS-189&t-I(Rev.01/10) Nam/Decreased Page 3 013 9