Copper, Barbara A. Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: FO( *v+j1�Rpt 404f RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: sl 10 �
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
1,4RDQflus
NAME: COWEQ CASE # 00
TYPE OF CONTAINER: ?,.4,6 41-4nt f
PLACE OF DEATH: IgZ'(� 911(s,ou Rai Vlet�1 11137
ESTIMATED WEIGHT OF REMAINS & CONTAINER 7f I
PLACED IN HOLD: I� pin
PLACED IN REFRIGERATION: II
DATE OF CREMATION: 511
l 3
TIME STARTED: 1.00hl TIME COMPLETED: 2
PLACED IN RETORT: I "��C 1 MOVED: Z'�r� r �•��[
RETORT # IN WHICH REMAINS WERE CREMATED: sqP z
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 NYS DeF,a burnt of state
Dmeion of Cernewas
One Commerce Plaza.99 Washington Avenue
AbWY.NY 12231
(518)474-6228
www.dos.stata.ny.us
This Authorization Form must be completed and signed prior to delivery of remains for cremation.
Date: April 29A,2020 Number: y$�
Crematory Name: Pine view Crematory
Address: 21 Quaker Road,Queensbyg,NY 12804
Phone: (518)7454476
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation is carried out by placing the remains of the deceased and4he 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 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.
IDENTIFICATION OF DECEASED
Name of Deceased: Barbara A Copper Marital Status: Never Married
Last Known Address: 182-15 Hillside Avenue,Jamaica,NY 11432
Place of Death: Hillside Manor Nursing Home, 182-15 Hillside Ave,Jamaica,NY 11432
Sex: ❑M OF Age: 57 DOB: 2/21/1963 Date of Death: 4/29/2020 Estimated Weight: 125lbs
Description of casket/container in which remains will be delivered:
Particle Board Cremation Container
PERSON IN CONTROL OF DISPOSITION
(Persar(s)in control of disposlt n, l 'lal E of the fallowing)
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-
`S I�S 1AAle 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 her remains and (continued next page)
Barbara A Copper
DOS-1898-f-I(Rev.01/10) Name of Deceased
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 ( b
cremation of the remains of the deceased. My/Our relationship to the deceased Is as follows:
(Insert firm the list below)
Number. 7 Description: Cousin of the deceased 3
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,
S.A lawfully appointed guardian;
7.Any person(s) eighteen years of age or older entitled to share;in the estate and who istare closest in
relationship to the deceased;
a.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)
(dal L THREE of the following)
INVe 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 remove these items prior to cremation may result In harm to the crematory and
crematory personnel.
Csp INVe hereby affirm that instructions have been given to(funaraldlrmcrorname) 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. (mmaroryname) 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.
`.� I/We hereby authorize(crematory name) Pine View: Crematory remains of the deceased. to cremate the
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:
.��f J2.1RL )lJ fi�-� �'I�� L�Y'✓��'3"
If for any reason the person named above does not take poss ssion of the cremated remains,
(cremetaynameJ Pine View Crematory is authorized to give possession of the remains to
(ronaral mom n me) Fox Funeral Home, by delivery in person or by registered mail.
DOS-189844 Barbara A Co er
(Rev.01/10) Name of Deceased
Page 2 of 3
t' !the following)
IANe understand that if the remains are not claimed within 120 days of cremation,
Wernetaynarne) may dispose of the remains in an irretrievable manner,
such as by scattering.
CREMATION CONTAINEEMRN
IFONE of the followings)
An um to be used as a container for the cremated remains has been purchased from
Fox Funeral Home,Inc. and is described as follows:
IMs understand that 9 the um is too small to hold the entire cremated remains, an additional rigid container may be
used for delivery.
O
� An um has not yet been purchased. I/We 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 aractorname) Thaddeus W. Baxter ,
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.
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,attest(s)to the accuracy and completeness of the Information contained In this
Authorization Form and authorize(s)the foregoing.
Signed this 29th day of April , 20 20 —7
Susan Kulikowsh Sanchez -
Typed or Pdnbd Name
313 North Emory Ave,Kissimmee,FL 34741
Address
Typed or Psi W Name Somme
Address
Typed o►PrhKed Name Signature
Address
WITNESS: /
C
Thaddeus W.Baxter
Funeral Dhector typed or Printed Name Fuleral Director Signature
10227
Registration Number
Barbara A Copper
DOS-1898-f-1(Rev.01110) Name of Deceased Page 3 of 3