Dore, Robert F. Pine View Cemetery & Crematorium
Quaker Road
Oueensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME:
REQUESTED RETURN TIME:
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
NAME:
-CASE 9
DATE OF CREMATION:
TIME STARTED. QQ
COMPLETED:
TYPE OF CONTAINER:
-
----------
------------
PLACED IN RETORT:
MOVED:
PLACE OF DEATH:
ESTIMATED WEIGHT OF REMAINS AND CONTAINER: Io2D t6-s
DATE & TIME REMAINS ARRIVED AT CREMATORY: ,77! ,Qq -------
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 BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
Authorization for Cremation and Disposition
ro dNrrrY N nNllaina ror crMr+uon.
Me AuNarlaaa.n Fom1 muar be eampN.d and NpIM
--
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(;romNOryN Pln=Vi,-(-mato -
rnone tt1%�RyS_11'1M1 -
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CREMATION la ad IRREVERaiBLE AND FINAL PROCEae.
CM,tT is Carried Oui l>y panrg Ua rMna1M d tha dse.saad and tM Nm'Ma! red rl�e rW
hall nil Me41n 1ata.
cremNion ch.mber where iMy are wbi.d.d ro Intense Mal and Soma
oneume ayaryrhlrq eaupt!none and metal,wllleh are all that MII M IeR atyr cfNnatlan.
Foll"ol er take
xnabwl cahamb.r.but Om.minithe—01-Y lma dual and roa1dW wiel%kaly M la"bahfrdroTM Vamslory w�Parala m
mr,,da—and Comb.matanal hom u+s remains and lt+a InrJdamal and loragn malsriN wire be dtepmed 1
I rsgwred by law.The cromaled nnnaina wm M__.he.�t IV m pulzedvor Ireo small places and placed M;a ``
dtagnat.d tomainer a um.c=-—.-a paMnlly an Wlvertrad until no NnaM Manta 1
reeoantrabl.air ak-I"I Ul au-
Or
OPENING OF r'ONTAINER.
The crematory mey oniY open 1M cnhts—,h deg the un-cromNetl human remans m YmilW Grcu:eta byee uch
n to cortfum tha damxy of meF ma. Iemalna arerdeavend In ontalner whkh in ot eu"Wa for cramatbn
damage crematory Property wal spuln that hate ramalne be movad Into a..Kable
suoh as•easmon4l or rental ueket.lM crematory,a eomalitsr nr the trensfer or ra nn,,.1 of remains yna be
container before R acpepta tha remains.The opening
conducted before a wdnesa and will be done in privacy,with dignity and sspeot.
IDE,NTIFIC UU N OF DECEASED
Mental Slalua' Nc�er Mwcied
Name of Deceased'._Robcn I*I-)— — - —
Last Known Address 144_61 38th Avenud.Flus_hin1t.NY.I 1354 — -. _
Plarut of Death. I.on¢island C8rc Crnler.144-61 38th Avenue,Flushing.NY 11354 -_---
Sax:OM OF Age, 91 ODe._ 3/3/1928 ,_ Date of Deeth'.aR04020_ Estimated Weight�dolby
Description of caelleticontsiner in which remains will be dellyered:
Wood C'ardhoard(Star 1-um1vl Suppl�')
pF�90H IN CONTROL OF DISPOSITION
(parson(,)in coning of disposition.I' I ONE Of the folbwirg)
I am/We are the designated agent of the deceased de tignaud in a wig or written instrument executed
pursu__ant to pudic Heahh Law section 4201.
-OR-
-- _ UWe have no knowledge that the deceased executed•written instrument pursuant to Public Heallh Law
section 4201 or a will containing directions for the disposition of his or her remains and 1Conbr lied M%I Puae)
iRohen F Dorc —
wm.
DOateabrJ(Rh'btnm
Pat;
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I arTV we am the Person(s)having prorrty under Public Health Law section 4201 and have the right to authorize
crem44011 of the remains of the decea»d My/Our relationship to the deceased is as follows.
(Insert trpm the 1,1i twbwl ✓
Number 7 Descrlpiron_ .ec.asomsiAwswrssial r omcasmmsewrss,.u,.aa.au..arn.eu,•- ••�•�,es'I:A
1.A person designated in wining pursuant to Public Health Law section 4201(3). Ate al"..rar
2.The surviving spouse.
2a,The surviving domesbc partner.
3,Any surviving child eighteen years of no or older
4.A surviving parent.
6.A surviving sibling eighteen years of age or older
6.A lawfully appointed guardian.
7.Any personi eighteen yeas of age or older entitled to share in the estate and who Were closest in
relstionshp to the deceased
6.A duty appointed fiduciary of the estate.
D.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 a Court
Procedure Act.
104.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)
jLatiliti ALL THREE of the foaokNng)
}, IN%hereby affirm that the body of this deceased does not contain a battery,battery pack,power cell,
vraddioactive Implant,or radioactive device and that any such materials were removed prior to the execution of this
Authonzallon Form,Failure to remove the"Items prior to cremation may mutt In harm to the crematory and
personnel. — —
ilWe hereby affirm that mstttxbons have been given to tn..rar wacti, Stern Utica _
regarding the removal of amy personal property or other thing of value which any person signing below or any family
member of the deceased wishes to preserve.tine o ryrwnl_ Pine View C'rcmelon` is not
responsible for removal of personal dems from"container or from the remar"of the deceased Personal items
left In the container or with the remains will he destroyed by the Cremation process and cannot be retrieved
1rCrem ehe - - — --
�'j/� IIWe hereby authorize(o.meav M,rt Pine View Cremation to eremaq the
remains of the deceased.
FINAL DISPOSITION
The person authorized to recerve the cremated remains of the deceased from the crematory is
Name Fox funeral Home.Inc.
—� — — ---- I719)268_
Address. 99-07 Ascan A%emr.Forest I ilk._NY.11375 - - Phone.77,1.J0t 1.9,l-,u,x
The cremated remains of deceased wil be disposed of as follows.
Puried at Cniv�aCcmete`m Woodside New York
If for any reason the person named above does not lake possession of the cremated rem airs,
,.,,rt_ Pine 1 icsk Crcma[off _ Is authorized to give possession of the remains to
tr,,,uw vmw_a ,— Fix runii IIonic.-[nc, _by delivery in person or by registered mail
Robert r Dore
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11 under.Wd Irat It U.e remain are nd cblmed-U-120 d.Y.of aemalron anner.
)1ns�.i<..Srcrnwea.. _.mar depose of fhe romans«,an mellwl6le m
.uoh ae 0Y a_ft Mg—
GREW T10N CONTAMlRnIRN
tfp�al ONE arere baw+.p)
_ An um to be used a.a Wr.,or for the crtmWed re.neins hn Eeen pvrchaseG from
Fox Funcrnl llnm�.1M'.__ aroude t,i,da.to$—
__ _
Ime understarw that a the um n too amalt to hold theanus aemaled remaa+s,an a maY be
used for de"ry
OSN/
An um fw not yal been OurGhesed. uroenUnd Thal d no um fa_Ch,aed or omarwtse w—ded
__Ptne V_�I:r`xmatnn wul piece Ins Gemalatl nmams m e raga temporary
i,ontarrer for dellwry.
The ANfonulon Form was pr d0d by
was eaeculed tl Ir„x.r ro.+^."'r' _ firx luncmt Homc lync. e Nmral director
e8-07 As.u_n�scnue.Fnrcst I{dIY�NY.1 i)75_ _snd ran signed byth
as IV&"..to as a%epNUM
IAbb have recewed a completed copy of this Authortzatlon Form.
The pereon(s)IdentllNd below Islam the parsons)In control of d{epoettlon,who by signing this
Authoriztlbn Fomrr attest(s)to the accuracy and Cortlpatellsse Of the Infomlatlen contained In this
Aulhodi,"on Form and allthorizo(s)the foragoing.
Signed this=1st__day of_ April
Lvfm An kh(j-MnL1 - - —.
renown U — sgNrun— U
123 Lockhevcn Road.W ick.R102889
Add""
WITNESS:
Smvcn Uuca -" .—.
Fu.a/a Nscro—TYW or ArMed riwns
,vNral Dlr.rlfl.s.p+.lum
14007
Arpnvakl'��n»e—.
NaMdpt are0 Pagld)
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