Willmen, Richard A. Pine View Cemetery & Crematorium �D I
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: Ill i
REQUESTED RETURN TIME:
NAME g.9OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING R
543�3
REMAINS:
NAME. - /v
..._CASE # `TO
DATE OF CREMATION:
TIME STARTED:
6o�
TYPE OF CONTAINER: - -- ---..-. --
,Cliff-f� 4 COMPLETED;
PLACED IN RETORT:
_ -
MOVED:
II
PLACE OF DEATH.• Q � t..--
__ c
ESTIMATED WEIGHT OF REMAINS AND CONTAINER:
..............
DATE & TIME REMAINS ARRIVED AT CREMATORY ------------
S�
PLACED IN HOLD:
PLACED IN REFRIGERATION:
RETORT # IN WHICH REMAINS WERE CREMATED:
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN
FROM TIME OF ACCEPTED DELIVERY: 4£3 HOURS
NOTE; THE CREMATION LOG SHALL BE RETAINED IN THE PERMANENT FILE 0F THE CREMATORY.
New York State
Department of State
NEW YORK Division of DIVISION OF CEMETERIES
STATE OF One Commerce Plaza
OPPORTUNITY. C@I'�1@tel"�@S 99 Washington Avenue
Albany,NY 12231-0001
Telephone:(5181474.6226
www.dos.ny.gov
Authorization for Cremation and Disposition
This Authorization Form must be completed and signed prior to delivery remains for cremation.
Date: 04/19/2020 Number:
Crematory Name: Pine View Crematorium
Address: 51 Quaker Road, Queensbury, NY 12804 Phone: (518)745-4477
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 THE 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 the crematory property. If
human remains are delivered in a container which is not suitable for cremation such as 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: Richard A Willmen Marital Status: Widowed
Last known Address: 30 Ledge View Drive, Queensbury, NY 12804
Place of Death: , 30 Ledge View Drive, Queensbury, NY 12804 275
Sex: ®M OF Age: 81 DOB: 10/14/1938 Date of Death: 04/17/2020 Estimated Weight lbs
Description of casket/oontainer in which remains Will be delivered.
Buffalo Casket Company—Alt container
PERSON IN CONTROL OF DISPOSITION
(Person(s)in control of disposition, initial 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 La Section 4201.
I/We have no knowledge that the deceased executed a written instrument pursuant to Public Health Law Section 4201 or a
con 'ning directions for the disposition of his or her remains and Itwe 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. Mylour relationship to the deceased Is as
follows:
Richard A Willmen
(Name or paces"d)
DOS-18984(Rev.08/15) Page 1 of 3
Authurkadw for Cremation and Disposition
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t Ci,aM a+asan rve'rie"T..'K norw'above does nc'ta+w tm wemicin r t tr:e crram8*we! w k-
Qine V'm, Crematanum
Regan Denny Steffort;-;:vrem;+trvw-
.mew Mor
Authorization for Cremation anq Disposition
(In the lowing)
Me understand that if the remains are not claimed within 120 days of cremation,
Pine View Crematorium may dispose of the remains in
(Akre&Crams"
an irretrievable manner,such as by scattering.
CREMATION CONTAINER/URN
(Initial ONE of the following)
Regan Denny Stafford
An urn to be used as a container for the cremated remains has been purchased from C,,,,era( Wf%m t
and is described as follows:
I/We understand that if the urn is too small to hold the entire cremated remains,an additional rigid container may be used for delivery.
-OR-
An urn is not yet purchased. INVe understand that if no urn is purchased or otherwise provided
Pine View Crematorium will place the cremated remains in
(Name of Cne—t-y)
a ngid temporary container for delivery.
This Authorization Form was provided by Mark J. DeSimone was executed at
(Fun"Oreckr Mwe)
Regan Denny Stafford Funeral Home
(Fun f Han.Naww)
53 Quaker Road, Queensbury, NY 12804
(FurwW Hare Ad"SS)
and is signed by the funeral director as witness to its execution.
I/We have received a completed copy of this Authorization Form.
The person(s)identified below islare the person(s)in control of disposition,who by signing this Authorization Form,attest(s)
to the accuracy and completeness of the information contained:inthis AudroNzatfon For and authorizes)the foregoing.
signed this 19th day of April 200 _
Scott Willmen
Typo O F►rr*W(Akre S J� y /�ns� /�
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Typed or fbnW Nam sonstum
tt
Typal or FYaded Name SgMk/e
Ad&os3
WITNESS:
Mark J. DeSimone
(FwwW D►mw Typo a FYmrod Name) (F )
10919
( �statan
Richard A Willmen
(N me of Df"S*Q
DOS-1898-f(Rev. 08/15) Page 3 of 3