Debanda, Rosario Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOMEkI4 IY\�
REQUESTED RETURN TIME:
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
V 1W1, �C ��Zlylc�ri�
NAME: S�lp_zsacc-() X' o(l(��G�. CASE # �� co
DATE OF CREMATION: "I-4-0?,o2C)
TIME STARTED: / „✓ TIME COMPLETED: "
TYPE OF CONTAINER: oco-c-) Ve A-tM� (-UP - 0 A ZD zY--vkC'b �jr)y6x/,,-
PLACED IN RETORT: MOVED:
►c PLACE OF DEATH: OW y AQ W cC f ff R ,''1-I M�-t%
K ESTIMATED WEIGHT OF REMAINS AND CONTAINER:
DATE & TIME REMAINS ARRIVED AT CREMATORY: '4�( �ZD7c� - 3d�1[•t
PLACED IN HOLD:
PLACED IN REFRIGERATION:
RETORT # IN WHICH REMAINS WERE CREMATED: �ot,J�(.r 6,4 ki
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.
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Authorization for Crematio and Disposition �__� NYS Department of State
Division of Cemeteries
One Commerce Plaza.99 Washington Avenue
j Albany,NY 12231
(518)474.6226
www.dos.state.ny.us
This Authorization Form must be completed and signed prior to delivery of remains for cremation.
Date: April 15`h. 2020 Number:
Crematory Name: Pine View Cremato w
Address: 21 uaker Road, ueensbu NY 12804
_ -- Phone: 518) 745-4476
CREMATION IS AN IRREVERSIBLE 4ND FINAL PROCESS.
Cremation is carried out by placing theremains of the deceased and the container holding the remains into a
cremation chamber where they are su jected to intense heat and flame. The heat and flame will incinerate and
consume everything except bone arid metal,which are all that will be left after cremation.
Following cremation, the crematory wil take reasonable efforts to remove all of the remains and other material from
the cremation chamber, but some mini al 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 decease I or to ensure that no material is enclosed which might injure employees or
damage crematory property. If human r himains 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 remah s. The opening of a container or the transfer or removal of remains will be
conducted before a witness and will be one in privacy, with dignity and respect.
IDENTIFICATION OF DECEASED
Name of Deceased: Rosario Debanda
—— — Marital Status: Married
Last Known Address: 144-06 88th Aver ue D2, Jamaica. NY 11435
Place of Death: Jamaica Hospital Medical Center, 8900 Van W ck Expressway,Jamaica,NY 11418 —
Sex: ❑M OF Age: 74 DOB: — 1/11/1946 Date of Death: 4/12/2020 Estimated Weight: _150lbs
Description of casket/container in which mains will be delivered:
Wood and Cardboard cremation containe
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PERSON IN CONTROL OF DISPOSITION —
(Person(s)in control of dispositio initial N of the following)
I am/We are the designated a nt of the deceased designated in a will or written instrument executed
pursuant to Public Health Law section 42 1.
-OR-
M h INVe have no knowledge that th deceased executed a written instrument pursuant to Public Health Law
section 4201 or a will containing direction for the disposition of his or her remains and (Continued next page)
Rosario Debanda _
DOS-1898-f-I(Rev.01i10) Name of Deceased
Page 1 of 3
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I am/we are the person(s) having priori under Public Health Law section 4201 and have the right to authorize /
cremation of the remains of the decea ed. My/Our relationship to the deceased is as follows:
(insert from the list below)
Number: 3 Description: Survivin 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;
5. A surviving sibling eighteen years of age or older;
6.A lawfully appointed guardian:
7.Any person(s) eighteen years of I 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 state;
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 r a public administrator appointed pursuant to the Surrogate's Court
Procedure Act; 1
10a. Any other person who is acting on behalf of the deceased and who has executed a written statement
pursuant to Public Health Law§4 01(7)
(initial ALL THREE of the following)
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tj_/_ INVe hereby affirm that the bodV 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.
--j tj iNVe hereby affirm that instructions have been given to(funeral director name) Thaddeus W. Baxter
regarding the removal of any personal p perty or other thing of value which any person signing below or any family
member of the deceased wishes to pres Drve. (crematory name) Pine View-Cremato r
responsible for removal of _- --- - _. _is not
personal item from the container or from the remains of the deceased. Personal items
left in the container or with the remai will be destroyed by the cremation process and cannot be retrieved
after cremation.
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I/We hereby authorize(cremato name) Pine View Crematory to cremate the
remains of the deceased.
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FINAL DISPOSITION
The person authorized to receive the cre ated remains of the deceased from the crematory is:
Name: Fox Funeral Home. Inc.
--..-__--
Address: 98-07 Ascan Avenue, Forest ills. NY 11375 (718)268-
Phone: Z711(1471 6nR-7436
The cremated remains of deceased will b disposed of as follows:
Yet to be determined
If for any reason the person named abov, does not take possession of the cremated remains,
(crematory name) Pine View Crmator is authorized to give possession of the remains to
(funeral home name) Fox Funera Home, Inc. by delivery in person or by registered mail.
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DOS-18984-1(Rev.ovio) Rosario Debanda
Name of Deceased Page 2 of 3
(Initial the following) 1 L%
tj f _ INVe understand that if the remains are not claimed within 120 days of cremation,
(crematory name)___ — Pine View rematory may dispose of the remains in an irretrievable manner,
such as by scattering.
CREMATION CONTAINER/URN
(Initial ONE of the following)
An urn to be used as a contai ier for the cremated remains has been purchased from
— — —-- and is described as follows:
INVe understand that if the urn is too small to hold the entire cremated remains, an additional rigid container may be
used for delivery.
-OR-
-jI 11 _ An urn has not yet been purct ased. INVe understand that if no urn is purchased or otherwise provided
(crematory name) _Pine View emato will place the cremated remains in a rigid temporary
container for delivery.
The Authorization Form was provided b (funeral director name) _ Thaddeus W. Baxter
was executed at(funeral home name) Fox Funeral Home, Inc.
(funeral home address) — 98-07 Ascan Avenue. Forest Hills NY 11375 and is signed by the funeral director
as witness to its execution.
Me have received a completed copy ol 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 a curacy and completeness of the information contained in this
Authorization Form and authorizes) a foregoing.
Signed this — 15th day of —_AAril , 20 20
Maria Moralesuj
Typed or Punted Name
144-06 88th Avenue D2, Jamaica,NY H 435
Address
Typed or Punted Name Signature — — —
Address
Typed or Punted Name ---- Signature
Address
WITNESS: /
-I'liaddeus W. Baxter
Funeral Orrector Typed or Printed Name__ Fu erg/Director Signature
10227
Registration Number — —
I Rosario Debanda
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DOS-1898 f-I(Rev.01/10) --
Name of Deceased Page 3 of 3
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