Baumann, Christopher Frank Pine View Cemeter & 1133
y 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
. �Z __
DATE OF CREMATION: -
_CASE t�
�.� Zp
TIME STARTED;/
- `-� -- - -- TIME COMPLETED: J'
TYPE OF CONTAINER:
PLACED IN RETORT:
MOVED-
PLACE
_...__..
OF DEATH:1 r'
ESTIMATED WEIGHT OF REMAINS AND CONT 2JT(J
AINER.
ATE & TIME REMAINS ARRIVED AT CREMATORY: A�- d� 1
PLACED IN HOLD: /0
PLACED IN REFRIGERATION:
RETORT # IN WHICH REMAINS WERE CREMATED: s
DETAILED REASON FOR DECAY IF REMAINS WERE CREMA-FED MORE THAN
FROM TIME OF ACCEPTED DELIVERY: 4t3 HOURS
_.. ..... _..._ ................
NOTE; THE CREMATION LOG SHALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
New York State
Department of State
DIVISION OF CEMETERIES
NEW YORK Division of one Con Plaza
gg Washington one A Avenue
STATE OF
OPPORTUNITY. cemeteries Albany,NY 12231 0001
Telephone:(518)474-6226
www.dos.ny.gov
Authorization for Cremation and Disposition
This Authorization Form must be completed and signed prior to delivery of remains for cremation.
Date:
04/24/2020 Number:io_
Crematory Name:Pineview Crematory
Address: 21 Quaker Rd, 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 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 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 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: christopher frank baumann Marital Status: Married but separated
Last Known Address: 391 Riedel Avenue,staten island,new york, 10306
Place of Death: mount sinai, 1111 Amsterdam Avenue, New York, NY, 10025
Sex: ®M 0 F Age: 58 DOB: 06/29/1961 Date of Death: 04/18/2020 Estimated Weight: 01
Description of casket/container in which remains will be delivered.
Alternative Cremation Container
PERSON IN CONTROL OF DISPOSITION
(Person(s)in control of disposition, initial ONE of the following)
am/We are the designated agent of the deceased designated in a will or written instrument executed pursuant to Publi
Health Law Section 4201.
-OR-
I/We have no knowledge that the deceased executed a written instrument pursuant to Public Health Law Section 42(
will containing directions for the disposition of his or her remains and I/we are the person(s)having priority under Public Health L
Section 4201 and have the right to authorize cremation of the remains of the deceased. My/Our relationship to the deceased
follows:
New Leaf Cremation Christopher frank baumann
Baumann, Christopher (Name of Deceased)
TR042520_FH11/CO5/032 r
Di
Authorization for Cremation and Disposition
(Insert from the list below)
Number: 5 Description: Legal Healthcare Proxy
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 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 Section 4201(7).
(Initial ALL THREE of the following)
'U 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 crematory personnel.
I/We affirm that instructions have been given to Michael Noll
(Funeral Director Name)
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. Pineview Crematory 21 Quaker Rd, Queensbury, NY 12804
(Crematory Name)
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.
I/VVe hereby authorize Pineview Crematory 21 Quaker Rd, Queensbury, NY 12804
(Crematory Name)
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: virginia baumann-Nelson
Address: 391 Riedel Ave Staten Island, NY 10306 Phone: 7188123650
The cremated remains of deceased will be disposed of as follows:
If for any reason the person named above does not take possession of the cremated remains,
Pineview Crematory 21 Quaker Rd, Queensbury, NY 12804 is authorized to give possession of
(Crematory Name)
New Leaf Cremation
the remains to by delivery
(Funeral Home Name)
in person or by registered mail.
Christopher frank baumann
New Leaf Cremation
Baumann, Christopher (Name of Deceased) Page 3 of 4
DOS-18S TR042520_FH11/C05/032
y Authorization for Cremation and Disposition
(Initial the following)
_�I/We understand that if the remains are not claimed within 120 days of cremation,
Pineview Crematory 21 Quaker Rd, Queensbury, NY 12804 may dispose of the remains in
(Name of Crematory)
an irretrievable manner,such as by scattering.
CREMATION CONTAINER/URN
(Initial ONE of the following)
An urn to be used as a container for the cremated remains has been purchased from
and is described as follows:
I/We understand that if the urn is too small to hold the entire cremated remains, an additional rigid container may be used for delivery.
-`OIR�
�l An urn is not yet purchased. I/We understand that if no urn is purchased or otherwise provided
Pineview Crematory 21 Quaker Rd, Queensbury, NY 12804 will place the cremated remains in
(Name of Crematory)
a rigid temporary container for delivery.
This Authorization Form was provided by Michael Noll was executed at
(Funeral Director Name)
New Leaf Cremation
(Funeral Home Name)
3930 Long Beach Rd., Island Park, NY 11558
(Funeral Home Address)
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 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 24 2020
day of april 20
virginia baumann-Nelson
Typed or Printed Name sigfrature
391 Riedel Ave Staten Island,NY 10306
Address
State of
County of
The foregoing document was acknowledge before me this#3_day of 202_by who personally appeared who proved to me
on the basis of satisfactory evidence to be the person(s)whose name(s)is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the
same in his/her/their authorized capacity(ies),and that by his/her/their signature(s)on the instrument the person(s),or the entity upon behalf of which the person(s)acted,
executed the instrument
Notary Signature
Notary Stamp(frequently call the seal)
WITNESS:
Michael Noll
(Funeral Director Typed or Printed Name) (Funeral Director Signature)
I'fla �—
(Registration Number
>
New Leaf Cremation
Baumann, Christopher (Name of Deceased)
TR042520_FH11/C05/032
Page 4 of 4
DOS-1898-