Maharaj, Deonarine Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: 4)c���j
REQUESTED RETURN TIME:
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
NAME:
ATE OF CREMATION: ��ZZ,1W
TIME STARTED: ,� 1
_ — -------- -. _._.__...TIME COMPLETED:
jj--II aa --
TYPE OF CONTAINER:
PLACED IN RETORT-
PLACE OF DEATH: _. _*�sl13,5
.. l5y_I iq s
ESTIMATED WEIGHT OF REMAINS AND CONTAINER:
ATE & TIME REMAINS ARRIVED AT CREMATORY:
PLACED IN HOLD: /D:�
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 13E RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
Authorization for Cremation and Disposition y NY�,oral Department o��
One Commarm Plaza,99 Washington Avenue
Albany,NY 12231
(618)4744226
www.dos.state.ny.us
1000111
This Authorization Form must be completed and signed prior to delivery of remains for cremation.
Date: April 2011,2020 Number.
Crematory Name: Pine View Crematory
Address: 21 Quaker Road,Queensbury,NY 12804 Phone: (518)745-4476
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 wiN 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 taught 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 DECEMD
Name of Deceased: Deonarine Maharaj Marital Status: Married
Last Known Address: 78 Daramouth Street,Forest FBI%NY 11375
Place of Death: The Grand Rehabilitation And Nursing @ Queens, 157-15 19th Avenue,Whitestone,NY 11357
Sex. QM OF Age: 89 DOB: 5/23/1930� Date of Death: 4/19/2020 Estimated Weight: /2-0.1e-zs
Description of casket/container in which remains will be delivered:
zym u P boo —e' O
_ERSON IN CONTROL OF DISPOSITION
(Person(s)In control of disposition,kdki ONE of the fogowing)
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.
-OR-
r' =•$1/We have no knowledge that the deceased executed a written instrument pursuant to Public Health Law
s ' on 4201 or a will containing directions for the disposition of his or her remains and (Continued next page)
_Deocarine Maharai
DOS-1 NV4(Ray.01110) Name of Deceased Page 1 of 3
Scanned with CamScanner
._ s..w-as :ai c
1 aml we are the person(s)having priority under Public Health Law section 4201 and have the right to authorize b {
cremation of the remains of the deceased. MylOur relationship to the deceased is as follows:
(insert from the Rd below)
Number. 2 Description: Sumiving Spouse
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;
S.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;
ti.A duly appointed fiduciary of the estate;
9.A dose 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)
(/aitlaf ALL THREE of the following)
IANe 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
Authorization Form.Failure to remove these items prior to cremation may result In harm to the crematory and
crematory personnel.
IANe hereby affirm that instructions have been given to(runeraidirecforname) Thaddeus W.Baxter
regarding the removal of any personal property ov other thing of value which any person signing below or any family
member of the deceased wishes to preserve.(aamawymane) Pine View Crematory is not
responsible for removal of persona&items from the container or from the remains of the deceased. Personal items
left in the container or with the remains will be destroyed by the cremation process and cannot be retrieved
after cremation.
;S'a" [Me hereby authorize(aamakwYm me) Pine View Crematory to cremate the
ibenalns of the deceased. I
FINAL DISPOSITION
The person authorized to receive the cremated remains of the deceased from the crematory is:
Name: Fox Funeral Home Inc.
(718)268-
Address: 98-07 Ascan Avenue,Forest Hills,NY 11375 Phone: 7711(o,71691-76A6
The cremated remains of deceased will be disposed of as follows:
Yet to be determined
N for any reason the person named above does not take possession of the cremated remains,
(aramataynanu) Pike View Crematory is authorized to give possession of the remains to
9"MWal how/WW) Fox Funcral Home,Inc. by deliveoy in person or by registered mail.
Dconarine Maharai
DOS-109M r(Rw.01no) Nuns ofDeosssed Pape 2 d 3
Scanned with CamScanner
(nfi the following)lowing) U
Me understand that if the remains are not claimed within 120 days of cremation,
fcidmetoy name) Pine View Crematory may dispose of the remains id an irretrievable manner,
such as by scattering.
CREMATION CONTAINERIURN
(Lnft 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:
INVe understand that if the um is too small to hold the entire cremated remains,an additional rigid container may be
used for delivery.
-0R.
An um has not yet been purchased. INVe understand that if no um is purchased or otherwise provided
(awreftymm) Pine View Crematory will place the cremated remains in a rigid temporary
container for delivery.
The Authorization Form was provided by&wal dirsorornama) Thaddeus W.Baxter
was executed at(rmwa ran.name) Fox Funeral Home Inc.
(turnrd home eddrm) 98-07 Ascan Avenue,Forest Mills,NY 11375 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 islare the person(s)in control of disposition,who by signing this
Authorization Form,attests)to the accuracy and completeness of the information contained in this
Authorization Form and authorize(s)the foregoing.
Signed this 20th day of April ,20 20 .
Shiroon MahArgi X - -
Typed or Pdided NameehNe
78 Dartmouth Strwt Forest Hills NY 11375
Address
Typed orPrU WNama SOON"
Address
Typed orPd0dsd Name SJ"t" -
Address
WITNESS:
Thaddeus W.Baxter
FWwW DndwTyped orPYGded Nerve Dtrsdor
10227
Pegab Ha1 Number
Deomme Maharaj
DOS-i OWN(Rev.01/1 o) Name of Deceased Paps 3 of 3
Scanned with CamScanner