Brown, Stennet Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME:Ao) U1 r cL,
REQUESTED RETURN TIME:
NAME Oy� \
F,FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
NAME: NWnet �► wo CASE #
DATE OF CREMATION: 1 170`tD
TIME STARTED: 1.00 AtlTIME COMPLETED: 3' '" 1
TYPE OF CONTAINER: !AIMD rfzAlME 2bTMVV\- CA2a� OVkCzi� 1��
PLACED IN RETORT: TIC MOVED: y
,C PLACE OF DEATH:
I-ESTIMATED WEIGHT OF REMAINS AND CONTAINER:
DATE & TIME REMAINS ARRIVED AT CREMATORY: �i' �207y - Z'30 PM
PLACED IN HOLD: 3'(U pri
PLACED IN REFRIGERATION: _
RETORT # IN WHICH REMAINS WERE CREMATED: Rgia— f
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.
Aatho&ation for Cremation and Die :itibrr
n ,or cemeWift
C v*Ceti Mme F UMM 991Miat r+Wn Avwm
ADarty.NY 12231
(518)474522E
www,das.slalr.iry.us
This AUdkWhadon Farm must be r.coed and signed prior to dWhwy of nuns&w for cremattom
Deter: Aprf1 16,2020 Number; 3 L
Cremtatwy Name: Pine View Cremator
Address- 21 Quaker Road,Quo=btuy,NY 12804 Phone:� �I S H5-�76
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation is carried out by placing the remains of the deceased and the container houng the rerr%Nns into a j
OrW18tion dumber where they are subjated to:ttense heat and tt me.The heat and flame will incinerate and
cananme everything except two.►and metal,which are&It that will be hwft attar cremation.
Following aviation,the crematory wiq twice reasonable dfa is to remove all of flue remains and other material from
the cremation chamber.but some minimal dust and residue wall likely be left behind.The crematory will serrate
inddiental and forte mattenal from the remains and the incidental and foreign material will be disposed of as
required by law.The cremSted remains wiil be mechanically pulverised into small pieces and placed into a
designated=itaiiner or urn. Cremated remains generally are pulverized unt1l no single€ragment is
nKognizable as skeletal tissue,
OPENING OF CONTAINER.
The crematory may only open the container holding the un-cmmeted human remains in limited ciacurnstances, such
as to confirm the identity of the deceased or to ensure that no materiad is enclosed which might injure employees or
damage crematory properly.If human rernains are delivered in as container which is not suitable for crernaticm
such as a cwwrmnlal err nMUl Casket the crematory wltl rvlluire that the remains be moved into a suitable
container before it accepts the remains.The opening of a container or the transfer or mmovat of remains%ill be
conducted before a w4ness and wW be done in privacy,with digrdty and respect
1DElM BFICAT19H OF MEMO
Name of Deceased: Stennet Rro%m Marital Status: NevrT'Man icd
Last Known Address: 170-03 Baisley Blvd-Jamaica,NTY 11434
glace of Death: _2uetns Efvspitat Ce=nccr,$2-6$ 164th Strew.Jamaica,NY 11418
Ser- E6M OF Age: 82 1306:_4d19,1937 — Date of Death_ 411212020 Estumated Weight;_ 700 _
Descripbon of c aaketrcontairm in which remains will be delivered:
MR SON IN QQNTRaL OF Q*PCISITION
tPersarrls)in ombDO ofd m.kgy CWF atft meowing)
_ I am/We are the designated spent of the deo"sod designated in a will or written instrument executed
pursuant to Public HMmIth Law section 4201.
.OR-
- IM e have no knowledge that the deceased wmcLded a written instrument pursuant to Public Health Law
section 4201 or a will containing drections for the disposition of his or her remains and tC wuw nexrpow1
Stennet Brown _
00S•1iltie44 i(IteY_erne► rraM oIDedemed 1 of 3
I arrV we are the persons)having prionty under Public Health Law section 4201 and have the right to authorize
cremation of the remains of Me deceased, MyADur relIxtiontship to the deceased is as follov a: -
(lassrt From the k t bsrbwwl
Number ; Desoiption: Surviving Child
I.A.person designated in writing pursuant to Pubbe Health Law section 4201(3).
2.Ttte surviving spouse;
2a.The surviving domestic partner:
3.Any surviving mild 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 persons) e~years of age or rstder entitled to share in the estate anci who Wwre closest in
relationship to the deceased;
8.A duly appointed fiduciary of the estate:
Q.A close friend or relative who has executed a written statement pursuant to Public Health Law§a201(7);
10.A chief fiscal officer of a county or a public admiristrator appointed pursuant to the SurrogaWs Court
Procedure Act;
ids.Any other person who is acting on behas3f of the deceased and who has executed a written statement
Pursuant to Public Health Law§4201(7)
&r&I ALL THREE of the fb Wm*ngrj
WM hereby affirm that the body of the deceased does not contain a lottery, battery pack,power cell,
radioactive implant,or radioactive device and that any such materials were removed prim to the execution of this
Autharizoon Farm. Failure to remove areas Hann priori*carnation may moult in harm to the crematory and
crematory personrioi,
L'�_Me hereby affirm that instructions have been given to ram* i4veelnrme ) _ , Thaddeus W_Baxter
regarding the removal of any personal property or other thing of value which any person s fining below or any family
member of the deceased wishes to preserve_(cnrmwv no"i Fine View Cre=toTy- _is not
responsible for removal of personal items from the container or from the remains of the deceased. IPenwinal Awns
left in the conbiirw or vdkh Ito remains vwfM be destroyed by Ito cremation process and cannot be retrieved
after cremwition.
CM6 UWe hereby authov"wer fr ! Pine View rem-dory to tromats the,
remains of the demased
FINAL QISpOcS1pm
The person authorized to rsc*ivw the cremated remains of the deceased from the oterreatary is:
Nerve. Fox Futvcral Ilome,Inc.
(719)269.
Address: 9$-07 elscan AvenucTFc}cest Hills.NY 11375 _ _ _ Phone:T71114171 EM �_
The cremated remains of used will be disposed of as follows:
Yct to be determined
If for arty reason the person named above does riot take possession of the cremated remains,
ta•maxxrr�f+oel _ Pine View Crematory is authorbod to give posseasion of the remains to
MM"arras MM)_ Fox Funeral Horne,Inc.� � by delivery in person or by registered mail_
Strand Brownl _
t1 OW M"(FW.D1119) NW"of DOZZWO Pape 2 of 1
.A 14
a Y
�w"�' 'U�ltadoearirr2)
&ANA INVo understand that if the remains are not claimed w7tWn 120 days of cremation,
tWOMerorr 4&Mi Pine View C.'zc=ory rn r dispose of the remains in an i retrievable manner.
such as by scattering..
CRR AM!PQNTAlNF„_RNRti
(JEW ONE of the Wmmog)
An um to be used as a container for the cremated remains has been purchased from
and is described as follows;
Me understand that if the urn is too small,to hold the entire cremated remains,an addrbonal aged container may be
used fcr delivery.
-OR-
CM.6 An urn has nest yet been purchased. Me understand that if no um is purchased or otherwise provided
(C*ftWkWY AWa) Pine View Crematary _._ will place the cwnated remains in a rigid temporary
container for delivery,
The Authorize Forrn was provided by(Affw*,*w4ornen+dl __m _.. Thaddeus W.Ba=.
was executed at MvmwjPm. na"i Fox Funczal Home, Inc_
;n"re home ad"") 9M7 Ascan Avenue._Forest-Hit i_s,.,^+iY 11.375 and is sagned by the funeral director
as witness to its exec Aon.
WUe have received a compieted coR of this Auftwizabon Form.
The pamon(s)identlAed below Were dw person1s)in control of disposition,who by signing this
Authors ion Form,attea#a)to the acweacy and eornplsteenrss of the information contairwd in this
AuthorizAtion Fomn and audwrlm(s)tM fevnWing.
53gned this Ibtla dsy of _ 4 ril ,20 20
CfJUettc Brm*M X ('MA-D is r.
')724 Esswhestcr Road,Bumar,'•.*IY 10469
Address
rypee or Prinrea h�ra
AdidR=
_7'y�crPmjftd wme
AdeYress
ti
Thadcims'Vw.iA="
Furwat oftuwr 7VPW or Pwired Ammo Ftwww Dked r Sinus
10227
_ ..
MKOMMn
Stennet Brown
008-895-H iRev.Mile) Mww dDecoamot Page 3 03