Vizioli, Fernando G Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: ` v1 Fi�� 4
REQUESTED RETURN TIME:
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
L
NAME: e(rifj�i7uU
DATE OF CREMATION:
TIME STARTED: �;]G�/�.}-�
--.....
..._.TIME COMPLETED:
TYPE OF CONTAINER:
M.-
LACED IN RETORT;
_-
PLACE OF DEATH I
- l `
ESTIMATED WEIGHT OF REMAINS AND CONTAINER: Z�
.._/
DATE 8 TIME REMAINS ARRIVED AT CREMATORY:
PLACED IN HOLD:
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 BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY
AaMorization for Cremation and Disposition J NYS Department of State
Division of Cemeteries
One Commerce Plaza,99 Washington 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: 04/13/20 Number: Z
Crematory Name: Q
Address:�� pU( d �ens 1 a FOY Phone:(5
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 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.
IDENTIFICATION OF DECEASED
Name of Deceased: Fernando G Vizioli Marital Status: Divorced
Last Known Address: 68-20 Selfridge Street AP. 3K, Forest Hills,NY 11375
Place of Death: 68-20 Selfridge Street AP. 3K, Forest Hills,NY 11375
Sex: LAM ❑F Age: DOB: 3/4/1947 Date of Death: Estimated Weight
Description of casket/container in which remains will be delivered:
Wood cardboard cremation container 5W Fq6,,0L' 5w fP i 2—
PERSON IN CONTROL OF DISPOSITION
(Person(s)in control of disposition, jaaL@J 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.
�4201
/We have no knowledge that the deceased executed a written instrument pursuant to Public Health Law
s i n or a will containing directions for the disposition of his or her remains and (Continued next page)
Fernando G Vizioli
DOS-18984-1(Rev.01110) Name of Deceased Page i of 3
Y I *W we are the Person(s) having priority under Public Health Law section 4201 and have the right to authoriz 7
cremation of the remains of the deceased. M /Our y relationship to the deceased is as follows:
(Insert from the list below)
Number: 3 Description: Any surviving child eighteen years of age or older.
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;
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§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)
(I " A L THREE of the following)
I/We hereby affirm that the body of the deceased does not contain a battery, battery pack, power cell,
ve implant, or radioactive device and that any such materials were removed prior to the execution of this
Author' ation Form. Failure to remove these items prior to cremation may result in harm to the crematory and
c t ry personnel.
IMe hereby affirm that instructions have been given to (funeral director name) Steven Duca
r ' g the removal of any personal property or other thing f value hich an perso signing below or any family
member of the deceased wishes to preserve. (crematory name) r M� pr,.; 0 ILA is not
responsib for removal of personal items from the container or from the remains of the deceased. Personal Items
rleft in the ontainer or with the remains will be destroyed by the cremation process and cannot be retrieved
a m tion.
e hereby authorize(crematory name) r �,t4.0 Cr to cremate the
of the deceased.
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 Ascan Avenue, Forest Hills,NY 11375 Phone: (718) 268-7711
The cremated remains of deceased will be disposed of as follows.-
Yet to be determined
If for any reason theperson7med above dcps not take possession of the cremated remains,
(crematory name) Q is authorized to give possession of the remains to
(funeral home name) Fox Funeral Home,Ync by delivery in person or by registered mail.
Fernando, G Vizioli
DOS-1898-f-I(Rev.01/10) Name of Deceased Page 2 of 3
._4Wame
ow'e understand that if the remains are not claimed within 120 days of cremation,
(cre
)) may dispose of the remains in an irretrievable manner,
such as by scattering.
CREMATION CONTAINS lUgN
(Initial 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 cremated remains, an additional rigid container may be
used fo delivery.
An urn has not yet been purchased. IMe understand that if no urn is purchased or otherwise provided
(cram
ato name) will place the cremated remains in a rigid temporary
container for delivery.
The Authorization Form was provided by (funeral director name) Steven Duca
was executed at (funeral home name) Fox Funeral Home Inc.
(funeral home address) 98-07 Ascan Avenue, Forest Hills, NY 11375 and is signed by the funeral director
as witness to its execution.
IMe 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 13th day of Aril , 20 0
Veronica Vizioli
Typed or Printed Name Signa re
819 Orchard Tree Road, Odenton, MD 21113
Address
Typed or Printed Name Signature
Address
typed or Printed Name Signature
Address
WITNESS:
Steven Duca
Funeral Director Typed or Printed Name Funeral Oi or Signature
14007
Registration Number
Fernando G Vizioli
DOS-1898-f-I(Rev.om o) Name of Deceased Page 3 of 3