Salas-Almachi, Patricio Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: fitI,0K- T 0WLrr- RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: SI1 I ZD 1 1
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
Rayy- t FW
NAME: ?RTCtcu AboPtCk CASE # Qb
TYPE OF CONTAINER: CApppmyp 0600 W�ft
PLACE OF DEATH:
ESTIMATED WEIGHT OF REMAINS & CONTAINER I-70 6r 76 /,6
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION: !!!r--/-ZO 2�
TIME STARTED: 6 loln TIME COMPLETED: �eLKO�2s?-i
PLACED IN RETORT: 0 MOVED:
RETORT # IN WHICH REMAINS WERE CREMATED: �
e� G/ flL
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 Disrrl�osition NYS Department of State
N 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: J Number: q9L
Crematory Name: Pine View Cemetery&Crematorium
Address: 21 Quaker Road Qt� .rs J tzN� Phone: S" 1
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 seperate
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: Patricio Salas-Almachi Marital Status: Married
Last Known Address: 329 Grant Street Bsmt Brooklyn NY 11208
Place of Death: The Mount Sinai Hosptial
Sex: [ 11 F Age: 73 DOB:March, 17 1947 Date of Death:April, 23 2020 Estimated Weight: J-6
Description of caske onta'iner 'n which remains will be delivered:
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 designated in a will or written instrument executed
pursuant to Public Health Law section 4201.
-OR-
S • I/We 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)
Patricio Salas-Almachi
DOS-1898-f-I (Rev.01/10) Name of Deceased Page 1 of 3
1 al 111 r,-i Gilt Ulc 'dcl JV11,J1 1lavll Iyj iJI IVI II'I UIIVGI I U►nIV I Ica1lI1 Lavv JG VU VII TLV 1 al lu Marc U1ri 11111 I1 lV GiUU 1V114-c
cremation of the remains of the deceased. My/Our relationship to the deceased is as follows:
(Insert from the list below)
Number: Description:
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.Any 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).
(Ini ial ALL THREE of the following)
S�S I/We 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.
S-S I/We hereby affirm that instructions have been given to(funeral directorname) Arlene Ross
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 Cemetery&Crematorium 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.
_IlMe hereby authorize (crematory name) Pine View Cemetery& to cremate the
remains of the deceased. Crematorium
FINAL DISPOSITION
The person authorized to receive the cremated remains of the deceased from the crematory is:
Name: 1EX
Address: C 6Y%�- �UY=Ny � 0 82WW /�� fl/ � 117p� Phone: �/�
a
The cremated remains of deceased will be disposed of as follows:
� id �I�wrw1.
If for any reason the person named above does not take possession of the cremated remains,
(crematory name) Pine View Cemetery&Crematorium is authorized to give possession of the remains to
(funeral home name) Frank J. Barone Funeral Home by delivery in person or by registered mail.
Patricio Salas-Almachi
DOS-1898-f-I (Rev.01/10) Name of Deceased Page 2 of 3
understand that if the remains are not claimed within 120 days of cremation,
(cramatoZe
Pine View Cemetery& Crematorium may dispose of the remains in an irretrievable
such as by scattering.
CREMATION CONTAINERMRN
Initial ONE of the following)
( An urn to be used as a container for the cremated remains has been purchased from
Frank J. Barone Funeral Home 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 for delivery.
-OR-
6 S An urn has not yet been purchased. I/We understand that if no urn is purchased or otherwise provided
(crematory name) Pine View Cemetery& will place the cremated remains in a rigid temporary
container for deliQp§natonum
This Authorization form was provided by (funeral director name) Arlene Ross
was executed at (funeral home name) Frank J. Barone Funeral Home
(funeral home address) 4502 Avenue D Brooklyn, NY 11203 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 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 4)pn( day of 2 , 2p 0
Sandra Salas
Typed or Printed Name Signatu _
329 Grant Street Bsmt Brooklyn, NY 11208
Address
Typed or Printed Name 4�re
Address
Typed or Printed Name Signature
Address
WITNESS:
Arlene Ross ,,
Funeral Director Typed or Printed Name Funeral Director Signature
Eq ?)] Q f
Registration Number
Patricio Salas-Almachi
DOS-1898-f-I (Rev.01/10) Name of Deceased Page 3 of 3