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Abbale, Victoria Pine View Cemetery & Crematorium Quaker Road Queensbury, NY 12804 (518) 745-4477 or (518) 745-4476 FUNERAL HOME: REQUESTED RETURN TIME: NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS: NAME: DATE OF CREMATION: '4/-2,0 -2vZo TIME STARTED: COMPLETED: TYPE OF CONTAINER: PLACED IN RETORT: l©v�Q� / PLACE OF DEATH-. ............. _jIo5f0,�1 ESTIMATED WEIGHT OF REMAINS AND CONTAINER: Qd DATE $ TIME REMAINS ARRIVED AT CREMATORY: /1.}^ _ _ �1.Z0`7.0 PLACED IN HOLD: PLACED IN REFRIGERATION: RETORT # IN WHICH REMAINS WERE CREMATED: J>•��Q��G�,c1P/ pv k 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. NYS Department of State Authorization for Cremation and Disposition Division of Cemeteries one Commerce Plaza,99 Washington Avenue Albany,NY 12231 (518)474-6226 www.dos.state.ny.us This A odzadon Form must be completed and signed prior to delivery of remains for cremation. Date: Number: 2 Crematory Name: pz,�re" £ J Address: =1 out Phone:,Qe J4( W7 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 um. 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: Marital Status: Last Known Address: Place of Death: Sex: ❑M�F Age: DOB: •• Date of Death: (, Estimated Weight: Description of casketicontainer in which re ins will be delivered: k4At'�A y-t-e— ( a LJ �N PERSON IN CONTROL OF DISPOSITION (Person(s)in control of disposition, i .i 1 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. S.XI/We have no knowledge that the deceased executed a written instrument pursuant to Public Health Law ction01 or a will containing directions for the disposition of his or her r mains and (Continued next page) t4 — Page 1 of 3 DOS-189844 (Rev.01/10) Name of Deceased I am/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: Description: 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§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). (l LL THREE of the following) 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 A horization Form. Failure to remove these items prior to cremation may result in harm to the crematory and crt1lWe personnel. hereby affirm that instructions have been given to(funeral drrecwname) WYIAOdr J� regarding the removal of any personal property or other thing of ue which any,person signing below or any family member of the deceased wishes to preserve. (crematory name) ) is not responsible for removal of personal items from the container or from the remains of the deceased. Personal items le in the container or with the remains will be destroyed by the cremation process and cannot be retrieved a 71UMWehe ation. reby authorize(aematoryname) /;�i��'` � to cremate the remains of the deceased. FINAL DISPOSITION •� The person au9porized to r ive the cremated remains of the deceased from the crematory is: Name: y40� Address: Phone: The ated remains of deceased will be disposed of as ollows: � t If for any reason thy person named above does not take possession of the cremated remains, (crematory name) �� �`�� is authorized to give possession of the remains to (funeral Home name) by deC ery in person or by registered mail. DOS-189844 (Rev.01/10) Name of Deceased Page 2 of 3 i « 110wmg) Ime rstand that if the remains are not claimed within 120 days of cremation, (cre atarynarne) ,a �L��U [� V±n-L� may dispose of the remains in an irretrievable manner, such as by scattering- CCREMeTION CONTAINERIURN (In" 1 ONE of the following). An um 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 um is too small to hold the entire cremated remains,an additional rigid container may be tuseorelivery. An um s not yet been urchased. INVe understand that if no urn Is purchased or otherwise provided me) �+ o �`+ will place the cremated remains in a rigid temporary container for delivery. This Authorization Form was providsoy{funeral was executed at Mmerat home name} (tonerw home address)/M Lj ��,,�Jy ,� �_and is signed by the funeral director as witness to its execution. INVe have received a completed copy of this Authorization Form. The person(s)identified below Ware the pemon(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 regoing. Sign this day . d� Typed Pri W Name so O N Address - Typed or Panted Name Signature Address Typed or Pnnted Name Signature Address 77A S Funend Typed or Primed Herne ReftraUon Numbef Jzaa Page 3 of 3 DOS-189" (Rev.01110) Name