Capellan, Katia Maria Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME:
REQUESTED RETURN TIME: /I
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
NAME: --KA a n _.._�^ �.� (_..G4 �
/' ..�-
__CASE tt
ATE OF CREMATION: : 7�
TIME STARTED: (�
_.__....._..T.IME COMPLETED:
TYPE OF CONTAINER: STD_ .���.���k� _ �•�J.�`--_
-
PLACED IN RETORT: 35��»�
.__._._._.__..MOVED:
PLACE OF DEATH:
_ - �. -�ar�s-� _l•�`l/5-- /opt.o�_Gl�,f�s�- �r���J�115 ,,J!�
ESTIMATED WEIGHT OF REMAINS AND CONTAINER: 15211) 1j IG '
�13 7c
DATE & TIME REMAINS ARRIVED AT CREMATORY:
____ �--_ iQ�• ZO
....-..... ..........
PLACED IN HOLD:
PLACED IN REFRIGERATION:
RETORT # IN WHICH REMAINS WERE CREMATED: > v�
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
GAuthorization for Cremation and Dis osition NYS Depn State
P DivfDivisiono of f C Ceemeteries
One Commerce Plaza,99 Washington Avenue
Albany,NY 12231
(518)474-6226
www.dos.stats.ny.us
This Authorize ion Form must be completed and signed prior to delivery of remains for cremation.
Date: 04/16/20 Number: 72-
Crematory Name: _Pine View Crematory
Address: 21 Quaker Road, Queensbury,NY 12804 Phone: (518) 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 remains into a
cremation chamber where they are subjected to intense heat and flame. The heat and flame will incinerate and
iconsume 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 um, Cremated remains generally are pulverized until no single kagment is
recognizable as skeletal tissue.
OPENING OF 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 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: Katia Maria Canellan Marital Status: Widowed
Last Known Address: 71-20 110th Street,Forest Hills,NY 11375
Place of Death: Long Island Jewish Forest Hills, 102-01 66th Road,Forest Hills,NY 11375
Sex. ❑M C F Age: 80 DOB: 10/18/1939 Date of Death: 4/16/2020 Estimated Weight:
Description of casketteontainer in which remains will be delivered:
Wood cardboard cremation contain 3
PERSON IN CONTROL OF DISPOSITI N
(Person(s)in conhol of disposition,�t (ONE of he 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.
-O
I/We have no knowledge that the deceased executed a written instrument pursuant to Public Health Law
ction 4201 or a will containing directions for the disposition of his or her remains and (ca*xiod next pope)
D08.189&M(Rev ovto) .-Kuria Maria 1pc Ilan
Name o/Dec"s of f Pape i of 3
I aml 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. My/Our relationship to the deceased is as follows:
(Insert from the list below)
Number. 3 Description: Any survivina child eiahteen years of ane 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;
9.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 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§4201(7)
( ALL THREE of the following)
IAIVe 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
ry personnel.
c sto
IIV11e hereby affirm that instructions have been given to IfUWnVaiWWnamel Steven Duca
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. 1«mmi y na- ,l Pine View Crematory is not
responsible for removal of personal items from the container or from the remains of the deceased. Personal ibms
left in the container or with the remains will be destroyed by the cremation process and cannot be retrieved
afte L
mation.
I/We hereby authorize(cmmwwyno=) Pine View Crematory to cremate the
ins of the deceased.
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 Avenue,Forest Hills,NY 11375 s _ Phone: (718)2 8-7711 _
The cremated remains of deceased will be disposed of as follows:
Yet to be determined
If for an mason the
Y person named above does not take possession of the cremated remains,
1 ►+hvyJ Pine_View Gtrmatory� _ is authorized to give possession of the remains to
(turner norm ns►n.).._______ _ Fox Funeral Homc, L,c. _ by delivery in person or by registered mail.
kutia Maria Ulan
oos-Ieoe ra mw,ov1oi aarowa _-_ .___
P.oexa3
the following) Q)
IMe understand that if the remains are not claimed within 120 days of cremation,
(Cremetoryname) Pine View Crematory may dispose of the remains in an irretrievable manner,
such as by scattering.
CREMATION CONTAINER/URN
( ij r l�(' ONE of the following)
An um to be used as a container for the cremated remains has been purchased from
Fox Funeral Home Inc. and is described as follows:
Me understand that if the um is too small to hold the entire cremated remains, an additional rigid container may be
used for delivery.
_ ;OR-
)Mk— An um has not yet been purchased. UWe understand that if no urn is purchased or otherwise provided
(�+fmyMM) Pine View— ematory will place the cremated remains in a rigid temporary
container for delivery.
The Authorization Form was provided by(funmw*ft-forname) Steven Duca
was executed at(run w/w"name) Fox Funeral Home Inc.
n em s) 98-07 Ascan Ave
as witness
Forest Hills NY 11375 and is signed by the funeral director
as witneses s to its execution.
I/We have received a completed copy of this Authorization Form.
The person(s)identified below islare the person(s)in control of disposition,who by signing this
Authorization Fonn,attest(s)to the accuracy and completeness of the information contained in this
Authorization Fonn and authorizes)the foregoing.
Signed this 16th day of April , 20 20 .
Danilo Rodriguez
Typed or Pnnted Name
I I I-10 76th Road Apt.2D,Forest Hills,NY 11375
Address
Typed or Pentad Name signature
Address —
T YPed or Prwava Nmm Signeturo
Address --�-----
WITNESS:
Steven Duca
Funeral Di►ecfa Typd or Prinbd any -Funeral Dubc_tor
14007
Regtstration Number
hutia Mari;t('ar�llan
DOS-189844(Rev.01/10) �--
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