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Avellaneda, Mercedes Pine View Cemetery & Crematorium 4 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: ck NAME: . j�. # - CASE _ _U__ ___ DATE OF CREMATION: TIME STARTED: TIME COMPLETED: TYPE OF CONTAINER: _Lc��JJO , ��n� l `d _._ PLACED IN RETORT: _An MOVED: PLACE OF DEATH ESTIMATED WEIGHT OF REMAINS AND CONTAINER: _ 17S-fl�S ATE & TIME REMAINS ARRIVED AT CREMATORY: 4/ -2v - 102.0 a - 00 PLACED IN HOLD: PLACED IN REFRIGERATION: pp�� RETORT # IN WHICH REMAINS WERE CREMATED: DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS FROM TIME OF ACCEPTED DELIVERY: TE: THE CREMATION LOG SHALL 13E RETAINED IN THE PERMANENT FILE 0F THE CREMATORY. New Yc " NEW YORK DIVISI011 Of DIVISION OF CEME'Department c STATE OF One Commerc OPPORTUNITY- Cemeteries 99 Washington Albany,NY 122 Telephone:(518)4, www.do! Authorization for Cremation and Disposition This Authorization Form must be completed and signed prior to delivery of remains for cremation. 4 Date: v`o ai`0 Number: 31?'S Crematory Name: v;e V C Address: d Slg 7196-k4 2-7 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, they are subjected to intense heat and flame. The heat and flame will incinerate and consume everything except bone and r 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 the remains and the incidental and foreign material will be disposed of as required by law. The cremated remains will be mechani pulverized Into small pieces and placed into a designated container or um. Cremated remains generally are pulverized until ni 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 identity of the deceased or to ensure that no material is enclosed which might injure employees or damage the crematory property 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 F container or the transfer or removal of remains will be conducted before a witness and will be done in privacy,with dignity and resl IDENTIFICATION OF DECEASED Name of Deceased: t*"-/Z( "465 v'5- h-,- '1E M9- Marital Status: Last Known Address: /0© " 4' 7-ro /2e,+)o 0 i f LLj /`" Y �7 Place of Death: v �- �!S �'?, ?9 t Sex: 13 M 13 F Age: 9, DOB: C �6 11?,AYDate of Death: Estimated Weight:f � Description of caskel/container in which remains will be delivered. c 1&e,6c(� J4ax !3-�'R CAS keA (2,,). „ PERSON IN CONTROL OF DISPOSITION (Person(s)iri 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 Put Health Law Section 4201. -OR- IlWe have no knowledge,that the deceased executed a written instrument pursuant to Public Health Law Section 420' containing directions for the disposition of his or her remains and I/we are the person(s)having priority under Public Health Lav Section 4201 and have the right to authorize cremation of the remains of the deceased. My/Our relationship to the deceased is follows: (Name of Deceased) DOS-1898-f(Rev.08/15) �RO y I d 2/�/ ��� r LG J /C41 age 1 Authorization for Cremation and.Disposition (Insert from the list below) Number: n� Description: Vt,,� 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)elghtedh years of age or older entitled to share in the estate and who is/are closest in relationship to the decew 8. A duly appointed fiduciary of the estate; 9. A close friend or relative who has executed a written statement pursuant to Public Health Law Section 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 qn behalf of the deceased and who has executed a written statement pursuant to Public Healti Law Section 4201(7). (Initial ALL THREE of the following) Me 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 remo% these Items prior to cremation may result In harm to the crematory and crematory personnel. IMe affirm that instructions have been given to J©5 C' (Funeral Director Name) regarding 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. , C OYl (Crematory Name) is not responsible for the removal of personal items from the container or from the remains of the de eased. Personal items left in tf container or with the remains will be destroyed by the cremation process and cannot be retrieved after cremation. \9'' \VWe hereby authorize �r 11�U i r (� C,r('►l(tTO U4 (Crematory Name) to cremate the remains of the deceased. FINAL DISPOSITION The person authorized to receive the cremated remains of the deceased from the crematory is: Name:_ l �5 r ce,cA J vle ZnC. Address:iLOL4 LIS Ave. ElMhWsi-, iJ 1 Phone:_IR—L12LI The cremated remains of deceased will be disposed of as follows: \l.IC�E:ca �t'.i2hew li If for any reason the person named above does not take possession of the cremated remains, �I n�V t t? W'• . l ' _,. rylC��C'��1 is authorized to give possession o (Crematory Name) the remains to G�f G\C(A �- t,i,C tyl T nC• by delivery (Funeral Home Name) in person or by registered mail. (Name of Deceased) DOS-18984(Rev.08/15) Page 2 of 3 Authorization for Cremation and Disposition (Initial the following) aAI/We understand that if the remains are not claimed within 120 days of cremation, 2-0 e-V k'e J') ( ccwab2 c N 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: Me 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 um is not yet purchased. I/We understand that if no um is purchased or otherwise provided /D;',,Nev%'e yo C ,-C MAt&('�1 will place the cremated remains it (Name o/Crematory) a rigid temporary container for delivery. This Authorization Form was provided by �L S— Jvr' `� was executed a (Fut4ral Director Name) e r�t`� � �?�,c�'t,�c� Inc• (Funeral Home Name) S-cry L/3 AVP E1✓hl)WCSt- KN i1311 (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 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 15 day of /I-/ L_ ,20 '� " v C Sf i t- � 13 L`)�� r1 �Ar T or Printed Name ' ture p0 � !o �`Zrir � D > �� �L 5 `� ll 3 73 Address Typed or Printed Name Signature A ss Typed or Printed Name Signature Address WITNES (Funeral Director Typed or Printed N me) (Fun I hector Signa ) a91 re um e (Name o1 Deceased) DOS-1898-f(Rev. 08/15) Page 3 of