Owens Florence P Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME:
REQUESTED RETURN TIME: NOif/�
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMA
INS:
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NAME: 0�ltnf
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DATE OF CREMATION: L _ ----
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TIME STARTED: f1� ��t� ..
.... .TIME COMPLETED:
TYPE OF CONTAINER:
t
PLACED IN RETORT:
M O V E D:
LACE OF DEATH
ESTIMATED WEIGHT OF REMAINS AND CONTAINER. gs_ -.-16s 73 C�iS
ATE 8 TIME REMAINS ARRIVED AT CREMATORY:
PLACED IN HOLD: /Q ..
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.
New York State
M Department of State
cEW YORK Division of DIVISION OF CEMETERIES
STATE OF One Commerce Plaza
OPPORTUNITY_ Cemeteries
99 Washington Avenue
Albany,NY 12 2 31-0 0 01
Telephone:(518)474-6226
www.dos.ny.gov
Authorization for Cremation and Disposition
This Authorization Form must be completed and signed prior to delivery of remains for cremation.
4/20/20 3 8�
Date: Number:
Crematory Name:
Pine View Crematory
Quaker Road, Queensbury, NY 12804 518-745-4477
Address: Phone:
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 disposeas 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
Florence P. Owens Widowed
Name of Deceased: Marital Status:
Last Known Address: 91 Library St., Warrensburg, NY 12885
Place of Death: Wesley Health Ctr., Saratoga Springs, NY 12866
Sex: El M El F Age: 98 DOB: 9/2/1921 Date of Death: 4/19/2020 Estimated Weight: 85
Description of casket/container in which remains will be delivered.
basic MacDonald Ceemation Container; cardboard
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 Law Section 4201.
-OR-
I/We have no knowledge that the deceased executed a written instrument pursuant to Public Health Law Section 4201 or a
r1lntaining directions for the disposition of his or her remains and I/we are the person(s) having priority under Public Health Law
n 4201 and have the right to authorize cremation of the remains of the deceased. My/Our relationship to the deceased is as
s:
Florence P. Owens
(Name of Deceased)
DOS-1898-f(Rev. 08/15) Page 1 of 3
Authorization for Cremation and Disposition
(Initial the following)
'&—I/We understand that if the remains are not claimed within 120 days of cremation,
ine View Crematory
may dispose of the remains in
(Name of Crematory)
an irretrievable manner, such as by scattering.
CREMATION CONTAINER/URN
(Initial ONE of the following)
An urn 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 urn is too small to hold the entire cremated remains, an additional rigid container may be used for delivery.
-OR-
r1x R An urn is not yet purchased. I/We understand that if no urn is purchased or otherwise provided
e View Crematory
will place the cremated remains in
(Name of Crematory)
a rigid temporary container for delivery.
Patricia Miller
This Authorization Form was provided by was executed at
(Funeral Director Name)
Brewer Funeral Home, Inc.
24 Church St., Lake Luzerne, NY 12846 (Funeral Home Name)
(Funeral Home Address)
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 is/are the person(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 foregoing.
Signed this 20 day of April 20 20
Joan Gallucci 1_ _
t�
Typed or Printed Name Signatur
91 Library Ave., Warrensburg, NY 12885
Address
Typed or Printed Name Signature
Address
Typed or Printed Name Signature
Address
WITNESS:
Patricia Miller \Pd4�
(Funeral Director Typed or Printed Name) (Funeral Director Signature
12465
(Registration Number)
Florence P. Owens
(Name of Deceased)
DOS-1898-f(Rev. 08/15) Page 3 of 3