Perez, Alfredo Pine View Cemetery & Crematorium `s
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME:
REQUESTED RETURN TIME:
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
- - ............
NAME:
_ ...-- ...___ -CASEDAT # �.
E OF CREMATION:
TIME STARTED;
-TIME COMPLETED: � G
TYPE OF CONTAINER:
PLACED IN RETORT: Ah
MOVED:
PLACE OF DEATH: J_ ia�. h Pius 102 Of
ESTIMATED WEIGHT OF REMAINS AND CONTAINER: _
ATE & TIME REMAINS ARRIVED AT CREMATORY: ZO
PLACED IN HOLD: lO:�lp
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 rHE CREMATORY
Authorization for Cremation and Disposition NYS Department of State
Division of Cemeteries
One Commerce Plaza,99 Woshington Avenue
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: 04/18/20 Number. �1 g
Crematory Name: Pine View Crematory
Address: 21 Quaker Road,Q.Reensbug,NY 12804 _ Phone: �i318)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 c i emaetion 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
i required by law.The cremated remains will 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 might 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.
IDENTIFIQATION OF DECEASED
Name of Deceased: Alfredo Perez Marital Status: Married
Last Known Address: 51-32 72nd Street,Woodside,NY 11377
Place of Death: Long Island Jewish Forest Hills, 102-01 66th Road. Forest Hills,NY 11375 _
Sex: ®M ❑F Age: 78 DOB: 9/21/1941 Date of Death; 4/16/2020 Estimated Weight: I?S,
Description of casket/container in which remains will be delivered:
Wood cardboard cremation container
PERSON IN CONTROL OF DISPOSITION
(Person(s)in control of disposition, AR&W ONE of the following)
1 am/We are the designated agent of the deceased designated in a will or written instrument executed
pursuant to Public Health Law section 4201.
'1We havwno knowledge that the deceased executed a written instrument pursuant to Public Hea
lth alth Law
section 4201 or a will containing directions for the disposition of his or her remains and (Continued next page)
Alfredo Perez
DOS-1898-f-I(Rev.01/10) Nama of Decwased Page 1 of 3
I am!we 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. My/Our relationship to the deceased is as follows:
(Insert from the list below)
Number: 2 Description: The surviving Souse
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 age or older entitled to share in the estate and who is/are closest in
relationship to the deceased;
9. A duly appointed fiduciary of the estate;
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 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)
l � HREE of the following)
1/We hereby affirm that the body of the deceased does not contain a battery, battery pack, power cell,
ra roactive 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
jarding
personnel.
I/W e hereby affirm that instructions have been given to(funeratdiractorname) Steven Duca a _
the removal of any personal property or other thing of value which any person signing below or any family
member of the deceased wishes to preserve. (crematory name) Nine View Crematory is not
responsible for removal of personal 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
0Qj!_cmqatlon.
krI11/We hereby authorize(crematory name) Pine View Cremato to cremate the
of the deceased. V _ —
FINAL DISPOSITION
The person authorized to receive the cremated remains of the deceased from the crematory is:
Name: Fox Funeral Home,Inc.
Address: 98-07 Asean Avenue. Forest Hills.NTY_11375 Phone: 718 268-7711
The cremated remains of deceased will be disposed of as follows:
To be taken to Mexico _
If for any reason the person named above does not take possession of the cremated remains,
(crametoryneme) _ _ Auie View Crematory _is authorized to give possession of the remains to
(runerathome nerve) Fox Funerat Home,Inc. by delivery in person or by registered mail.
_Alfreddo Perez
DOS-988S-f-1(Rev.D1 110) Name of Deceased Page 2 of 3
TCh
ollowing)I/We understand that if the remains are not claimed within 120 days of cremation,
oryname) Pine Vi C may dispose of the remains in an irretrievable manner,
s by scattering.CREMATION NT INE RN
On—dial ONE of the following)
An urn to be used as a container for the cremated remains has been purchased from
Fox Funeral Home, Inc. and is described as follows:
I/We understand that if the urn is too small to hold the entire
used for delivery. cremated remains, an additional rigid container may be
use
_ An urn has not yet been purchased, I/We understand that if no urn is purchased or otherwise provided
( mAtoryname) Nine View Cremator_ — _will place the cremated remains in a rigid temporary
container for delivery.
The Authorization Form was provided by(tonera/d/reciorname) Steven Duca
was executed at(funeral home name) —
_ Fox Funeral Howe, Inc. _
Uunerai home address)` 98-07 A_scan Avcn_ue, Forest Hills,NY 11375 _ and is signed by the funeral director
as witness to its execution.
Me 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 18th __day of _ Aril ,20 20_�—
Jqldwiga Perez
Typed or Printed Neme - -. -
51-32 72nd Street, Woodside,NY 11377
Address -— -- — — —
Typed or Printed Neme _ --- - -'
Address — -- -- _
Typed or Printed Neme Signature
Address
WITNESS:
Steven Duca_
yped or Printed Name Funeral Director Slgnetum - -
14007 _
Regiomtion Number -
Alfredo Perez
DOS 189t3•f-1(Rev 01110) Name of Deceased - i Page 3 of 3