McDonald, Lucien Clay Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: TiL
- - K--- .._ ` -4 ,tee_
REQUESTED RETURN TIME:
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
NAME: _CASE #
DATE OF CREMATION:
TIME STARTED: 7
COMPLETED:
TYPE OF CONTAINER:01M --
_
........._
PLACED IN RETORT: 7%
._ ._..MOVED
PLACE OF DEATH. n II
1�VC3?dC .� ;- ,Ta�`i/1•, /v ( �� _�(� acQ�2e�,�,v��
ESTIMATED WEIGHT OF REMAINS AND CONTAINER: �' p �/5�2�
DATE & TIME REMAINS ARRIVED AT CREMATORY: ZAP/Z0�0 /D"Jo
PLACED IN HOLD: I
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.
Authorization for Cremation and Disposition NY Divisiosio5 art Ce of State
n of metariea
One ComMOMS Ptata,99 Washington Avenue
Albany.NY 12231
(518)474$226
www-dos.state,ny.us
This Authorization Form must be completed and signed prior to delivery of remains for cremation.
Date: April 22,2020 _ �! Number:
Crematory Name: Pine View Crematory_
Address: 21 Quaker Road,Queen bury,NY 12804 Phone: 518 7454476
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 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: Lucien Clgy McDanald i _ _ _ i Marital Status: Divorced
Last Known Address: 10 Clinton Street 3P, Brooklyn, NY 11201
Place of Death: 1-Iolliswood Center For Rehabilitation And Nursing; 195-44 Woodhull Avcnue, Rallis,NY 11423
Sex: ®M ❑F Age: 88 _ DOB: 6/25/1931 Date of Death: 4/17/2020 Estimated Weight: /30_
Description of casketicontainer in which remains will be delivered:
Wood and Cardboard cremation container
PERSON IN CONTROL OF DISPOSITION
(Person(s)in conM of disposeo i i ONE of the following)
_ 1 am/We are the designated agent of the deceased designated in a will or written instrument executed
pursuant to Public Health Law section 4201.
pCition
JWe have no knowledge that the deceased executed a written instrument pursuant to Public Health Law
01 or a will containing directions for the disposition of his or her remains and (Continued next page)
Lucien Clay McDonald
DM-18WI-1(Rev.onto) Name of Deceased Page 1 of 3
I am1 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; Surviving Child
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)
*55vivl,
THREE or the fvttowing)
We hereby affirm that the body of the deceased does not contain a battery, battery pack, power cell,
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
Xregarditng-
ry rsonnel.
I e hereby affirm that instructions have been given to(hu�erdd&fttorname) Thaddeus W. Baxter
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. (crematory name) — ` Pine View Crematory _ _ _ 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
fte atlon.
re hereby authorize(crematwyname)_ Pine View Crematory — — _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: Fox Funeral Home. Inc.
Address: 98-07 Ascan Avenue, Forest Mills NY 11375 Phvne: (718)2b8- —
R-- --1 --__Ll — -- — - -MU10.L14U-3.23ii..
The cremated remains of deceased will be disposed of as follows:
Yet to be determined
If for any reason the person named above does not take possession of the cremated remains, —
tore+netoryname) — Pine View t'remator � is authorized to give possession of the remains to
(hrrrenwhwwn►eme) —_I-'ox Funeral Home, inc. _ by delivery in person or by registered mail.
Lucien Clav McDonald
DOS-1898-f I(Rev.o111o) Name o(Demased Page 2 of 3
)n, following}
INVe un derstand that if the remains are not claimed within 120 days of cremation,
matory namel—2LIle View Crematory
such as by scattering. _ may dispose of the remains in an irretrievable manner,
CREMATION CONTAINE n 11MIJ
(lnihal 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:
INVe understande um is too small to hold the entire cremated remains, an additional rigid container may used for delivery, y be
AUZ An urn has not yet been purchased. INVe understand that if no urn is purchased or otherwise provided
fcmmatorynenleJ_ _ Pine View Cremator — will place the cremated remains in a rigid temporary
ry
container for delive .
The Authorization Form was provided by(funeral dwmarnamo)
was executed at(runeraihome name)
— -- —_-- Thaddeus W. Baxter
—.Fox Funeral Home,Inc. —
(runerainame seeress) "— 9$-07�Ascan Avenue, Fnrest Hills,NY 11375 —
as witness to its execution.
— and is signed by the funeral director
I/We have received a completed copy of this Authorization Form.
The Person(s) identified below Isfare the person(*)in control of disposition,who by signing this
Authorization Form,attests)to the accuracy and completeness of the information contained In this
Authorization Form and authorize(s)the foregoing.
Signed this 22nd day of n ril
-- r 20 2
Lareal M. McDonald �
Typed or Printed Name — -— —
_917 Tuscanny St•} Brandon, 33511
Address FI,
—
4Ped�fed i iame —
5ignafure
- ----
Address — -- ----.�_ _
Typed or Printed Nar►Ae —
Sonature — _ —
Address—� — ---
WITNESS:
Thaddeus W. Baxter
Funeral b or Typed or Pnirleca'lVam®
1(}227
Funs f Director Signature
_ -- — _
Ragiafration Nixnber
DOS-1899-1-1(Rev,01/10) Lucien Clay McDonald
Name ar Deceased Page 3 of 3