Xu, Eric X. Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: 15�lL(a
REQUESTED RETURN TIME:
rNAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
�l(VlA VC
NAME: aJ I
............._CASE
DATE OF CREMATION: - .._
zy f tia
TIME STARTED: _______ _-`_-`—_ fl•UJ��TYPE OF CONTAINER: TIME COMPLETED:
NV (,�C _
PLACED IN RETORT: .MOVED
11 �r' 10 ... ' 1
_ __.
PLACE OF DEATH: 141-
ESTIMATED WEIGHT OF REMAINS AND CONTAINER:DAT �d
.... ..-.-...
E & TIME REMAINS ARRIVED AT CREMATORY: /
ACED IN HOLD:
PLACED IN REFRIGERATION:
RETORT # IN WHICH REMAINS WERE CREMATED: ^ p�
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.
Authorization for Cremation and Disposition C YS Department o1 state
Division of Cemeteries
One Commeme 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: April 22,2020 Number: Vo
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 an the container holding the remains into a
cremation chamber where they are subjected to intense heat and fl me. The heat and flame will incinerate and
consume everything except bone and metal,which are all that ill be left after cremation.
Following cremation, the crematory will take reasonable efforts to r ove all of the remains and other material from
the cremation chamber, but some minimal dust and residue will like) 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 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 c ntainer 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 containe r or the transfer or removal of remains will be
conducted before a witness and will be done in privacy, with dignity a id respect.
IDENTIFICATION OF DECEASED
Name of Deceased: Eric X. Xu Marital Status: Widowed
Last Known Address: 147-14 84th Road Apt. 6B,Briarwood, NY 114.35
Place of Death: 147-14 84th Road Apt. 6B,Briarwood,NY 11435
Sex: QM ❑F Age: 82 DOB: 8/23/1937 Date of Death: 4/21/2020 Estimated Weight: 1501bs
Description of casket/container in which remains will be delivered: 0
Wood and cardboard cremation container—Star Funeral Supplies
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 designa ed in a will or written instrument executed
pursuant to Public Health Law section 4201.
-OR-
aX [Me have no knowledge that the deceased executed a written instrument pursuant to Public Health Law
section 4201 or a will containing directions for the disposition of his or ler remains and (Continued next page)
Eric X. Xu
DOS-189844(Rev.01/10) 7me of Deceased Page 1 of 3
I am/we are the person(s) having priority under Public Health Law se tion 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: 3 Description: Surviving Child
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;
6.A surviving sibling eighteen years of age or older;
S.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 statemeni 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 a rid who has executed a written statement
pursuant to Public Health Law§4201(7)
Q&al ALL THREE of the following)
ax IMe hereby affirm that the body of the deceased does not c ntain a battery, battery pack, power cell,
radioactive implant, or radioactive device and that any such materials Nere removed prior to the execution of this
Authorization Form. Failure to remove these items prior to cremat on may result in harm to the crematory and
crematory personnel.
INVe hereby affirm that instructions have been given to(funs directorname) Thaddeus W. Baxter
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. (crematory name) Pine 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
after cremation.
_ate I/We hereby authorize(orematoryname) Pine View Crematory to cremate the
remains of the deceased.
FINAL DISPOSITION
The person authorized to receive the cremated remains of the deceas from the crematory is:
Name: Fox Funeral Home, Inc.
(718)268-
Address: 98-07 Ascan Avenue,Forest Hills NY 11375 Phone: 7711 f91 71 S5R-ER R
The cremated remains of deceased will be disposed of as follows:
Burial in a Cemetery
If for any reason the person named above does not take possession the cremated remains,
(crematory name) Pine View Crematory is aut orized to give possession of the remains to
(funeral home Hama) Fox Funeral Home,Inc. by delivery in person or by registered mail.
Eric X. Xu
DOS-1898 N(Rev.01/10) 1 fame of Deceased Page 2 of 3
(Ladkl the following) Lq)
1X Me understand that if the remains are not claimed within 120 days of cremation,
(crematory name) Pine View Crematory may dispose of the remains in an irretrievable manner,
such as by scattering.
CREMATION CONTAINERIURN
(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 f Ilows:
Me understand that if the um is too small to hold the entire cremate remains, an additional rigid container may be
used for delivery.
-OR-
ay _ An urn has not yet been purchased. INVe understand that if no um is purchased or otherwise provided
(crematory name) Pine View Crematory will place the cremated remains in a rigid temporary
container for delivery.
The Authorization Form was provided by(funeral director name) Thaddeus W. Baxter
was executed at (funeral home name) Fox Funeral Home Inc.
(funeral home address) 98-07 Ascan Avenue Forest Hills NY 1131 F5 and is signed by the funeral director
as witness to its execution.
IIWe 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 22nd day of April , 20 0
Agnes Xu X
Typed or Pnnted Name Signature
345 W 85th St.Apt. 52 New York,NY 10024
Address
Typed or Printed Name Signature
Address
Typed or Printed Name Signature
Address
WITNESS:
Thaddeus W. Baxter
Funeral Director Typed or Printed Name Fu rel Director Siitture
10227
Registration Number
Eric X. Xu
DOS-189V4(Rev.01/10) ame of Deceased Page 3 of 3