Cabansag, Carmelita Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: fo) fuwtz , yom� RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: r�l I ZO
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
'NA.PPEuS C�A�IT�SZ
NAME: C��h��, ���Ar SPilr CASE #
TYPE OF CONTAINER: 5�" �"`�/ IQr � Cj ca-A014
PLACE OF DEATH: 6111 "{! Ayleut q F UDdd flat M, 13`�
ESTIMATED WEIGHT OF REMAINS & CONTAINER 1/0 1k
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION: /� I zo
TIME STARTED: ��-� TIME COMPLETED: I %00�M
PLACED IN RETORT: All MOVED: 2.0
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.
Mhorizatic n for Cremation and Disposition NYS artment c
" Di of Cem.
One Commerce Plaza,99 hington P
Albany,NY
t518)47,c
_—. 's'staCE
This 4uthodZed
he
_ -00111pieted
_ - -Stgned prMr ro e very of remains or cremation.
ate: /-J) it 26"' 2020 Number:- --- - - - �,- - --- - --
,
idress: 21 (1uker Road, ueensbun. 'ti Y 12804
-- - _ _ -- - - Phone: (518) 745-4477
- - -- -- --- ---
:REMATION If AN IRREVERSIBLE AND F!N L _ -
.rema ion is ca ried out by placing the remains-of the deceased and the container holding the remains into a
remat0eve
onsuing except bone and metal, which are all that will be left after cremation. era a anc
m ve a o e remains and other material frc
ie crember, but some minimal dust and residue will likelybe left behind. The r r-ra}P
e remains and the incidental and foreign material will be disposed of squired by law. The cremated remains will be mechanically
esignated cont liner or um, Cremated remains generally are pulverized until no single fragment is
)Cognizable a skeletal ti_q_q1Jf%_
'ENING OF - - - - -- - -- -- -
e crematory m y only open the container holding the un-cremated human remains in limited circumstances-
e ecease or o ensure that no material is enclosed which might injure employees c
ma a crematoproperty. If human remains are delivered in a conta9A9F whmeh
ch as a cerem niail or rental casket,the crematory will require that the remains be moved into a suitable
iducted before witness and will be done in rivac , with di nit and r e transfer or removal of remains will be
pect
Me of Becess d annc a a a nsaa Marital Status: NVidcn3.ed
nown r ss: 6714 41 st Avenue Apt. 4F, Woodside, :\�' 1 _ _ -_ _ _ 1377' - -
ce of Death: 14 41st Ax-enue ARt. 4F_Woodside. NY 11,377 - - - - - - - -
❑M CQF Age: 78 DOB: 10,291]941 Date of Death: '') ;? " ght;ht - - - S
3cription of cas et/container in whichremains will N- delivered,
\J6od and Card B and Cremation Container - Star Funeral Supplies
-s n
I am/We are the designated agent of the deceased
want to Public Health Law section 4201,
.6
o knowledge that the deceased executed a written instrument pursuant to Public Health aw
:ion 4201 or
ae nex page
C'arnlelita C abansau
18 q ev.ovi o -- — — —
Name of Deceased 0=Page 1 of
aft we are the r erson(s) having priority under Public Health Law section 4201 and have the right to au ize ,
'e11112 of the remains of the deceased. My/Our relationship to the deceased is as follows:
asert from ttV list below)
asignated in writing pursuant lo Public Health Law section 4201(3);
2. T
2a. The survi ing domestic partner:
3. Any survivi ig child eighteen years of age or older:
6. A lawfully ppointed guardian;
7. Any perso (s) eighteen years of age or older entitled to share in the estate and who is/are closest in
fuldtiunshl ) to the deceased:
8. A
9. A close frie id or relative who has executed a written statement pursuant to Public Health
10. A chief fis al officer of a county or a public administrator appointed pursuant to the Surrogate's Court
Procedure Act,*
pursuant tc Public Health Law 4201 7
itial ALL THREE of the following)
I/V11e her aby affirm that the body of the deceased does not contain a ba e . batte
U.pack. Power cell,
Ifoactive implar t, or radioactive device and that any such materials were removed prior to the execution of this
4herizatiam F.-, , Failuiv to remove these 6terns pliut to j;IvIndtiun nay result in harm to the creMatory an
1matory pers nel.
VWIANe he by affirm that instructions have been given to hrn r r director me _ Thaddeus Baxter
larding the re val of any personal property or other thing of value which any person signing below or any famil)
(crematory name -_ _Phic le\K- rema orb _ - is not
onsible for noval of .Personal "tam
An the contai ter or with the remains will be destroyed by the cremation process and cannot be retrieved
rze(cnrmatory name) — line le�� remator� to cremate the
laths of the cea a _ -- - _ _ -- -�
G FRO
Foresi
NY
- -- _ i s -'15 one: 12I LL25SL44ZS
cremated ie, ains of deceased will be disposed of as followso
to t)e deteniiii ted
r any reason tie person named above does not take possession of the cremated remains,
Woryname) _ _ _ _ ine ie% C rema orb _ _ _ is au onze to give possession of the rema" to
C'annelita CabansL�g
18@W-P(Rev.0111 Name of Deceased _� cage 2 0
rVal oltowin
M/e understand that if the remains are not claimed within 120 days of cremation.
-ma ory name) Pine Vi xN _
:;h as by scatt ing. _
:EMATION CO AINER/URN
°ial ONE of the f flowing)
n urn t D be used as a container for the cremated remains has been purchased from
and is deseFibed as follows,
le understand at if the urn is too small to hold the entire cremated remains, an additional rigid container may t
-d for delivery,
An urn t ias not yet been purchased. IM a understand that if no urn is purchas-ad or nth ied
matoryname) — _ Pine View Cremator)•_- -- _ will place the cremated remains in a rigid temporar;
e Authorization Form was provided b (funeral director rn _ _ _ _ _ _ • _ _
s executed at uneral home name) I'ox Funeral Horne. Inc -
eral home a Tess —__ _ — _ --(+Forcst 1 1111s, qY_ ? —_ and is signed by the tuneraT direcT
1e nave receivf d a completed copy of this Authorization Form.
MUM ow islare Me persons in control of disposition, who By signing this
thorizabon F rm, attest(s) to the 2c"racy anti rnmgjlPtPnP-q-s. of thp informnfinn contained in this
thorization F rm and authorize(s) the foregoing.
;ned this 2 th day of Aril , 20 20 .
�5 Galicia Jr. - - - - - - - - X - - -- - - - -
me Sionature
Gloucester Cl(se Thames. Ditton. KT
cress -
Tress
d or Printed Name S n t re
ress
NESS: �}`t'�� V'-)
ZRIeus as e Z
Pal Director Typed o r Printed Name Fu ral Director Si n tur
,7
7ration Number
armelita C'ahansae _ _ _ _13
18ARJP(Rev.Ovi)) Name of Deceased a Page 3