Del Rosario, Kevin Bernabe Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: d-j _A— RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: -3O /z4 f Zoz,,2
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
/im C
"' eR DLio ram'
NAME: KEUI,-J /Jd k6sa,-r,o CASE #
TYPE OF CONTAINER:
PLACE OF DEATH: TJ 6yq-2_ /5� 21"�'9, �y / q Id o 2�,3
ESTIMATED WEIGHT OF REMAINS & CONTAINER 164 370 �►�t
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PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION: { ��� ,ZO
TIME STARTED: 7 ! I I TIME COMPLETED:
PLACED IN RETORT: 'O APMOVED: I:00A�IT_R �a �
RETORT # IN WHICH REMAINS WERE CREMATED: �ri.,� �
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.
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Authorization for Cremation and Disposition
p sition NYS Department or State
Division of Cemeteries
One Commerce Plaza,99 Washington Avenue
Albany,NY 12231
(518)474-6226
www.dos.state ny.us
This Authorizatfon Form must be compfated and signed prior to delivery of remains for cremation.
Date: 04/23/2020 _ Number: /
Crematory Name: Pine View Crematory
Address: 21 Quaker Road, Queensbury, NY 12804
Phone: 518 7.15-4476
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
i 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- Kevin Betnabe Del Rosario
Marital Status: Never Married
Last Known Address: 110-20 73rd Avenue Apt.6G, Forest Hills , NY 11375
Place of Death: Bellevue,First Ave. And 27th St., New York,NY 10023
Sex: EZM ❑F Age: 30 DOB: 11/27/1989 Date of Death: 4/23/2020 Estimated Weight: 175lbs.
Descnptlon of casket/container in which remains will be delivered:
r( Star Funeral Supply)
PERSON I 01 nF rm p glT1ON
(Person(s)in control of disposition, iM 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.
I/We have no knowledge that the deceased executed a wriften instrument
section 4201 or a will containing directions for the disposition of his or her remains and r(Continued suant to Public
Health Law
page)
Dos-lase r-t(Rev.01/10) Kevin Bemabe Del Rosario
Name of Deceased Page 1 of 3
M
I am/we are the person(s) having priority under Public Health Law section 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: 4 Description: A surviving parent;
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;
B. 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)
(l ' k ! LL THREE of the following)
I/We hereby affirm that the body of the deceased does not contain a battery, battery pack, power cell,
adioactive 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
c tory personnel.
I/We hereby affirm that instructions have been given t0(funeral director name) _Steven Duc;a _
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
Vremation.
I/we hereby authorize(crematory name) Pine View Crematory to cremate the
remains 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 the person named above does not take possession of the cremated remains,
(crematory name) Pine View Crematory is authorized to give possession of the remains to
(hmral home name) Fox Funeral Home Inc. _ ,by delivery in person or by registered mail.
Kevin Bernabe Del Rosario
DOS-1 ti98 f-1(Rev.01/10) Name of Deceased
Page 2of3
( ' the following) \�
NVe understand that if the remains are not claimed within 120 days of cremation,
as by S
such as by scattering.
i mst Pine View Crematory_ may dispose of the remains in an irretrievable manner,
��--
CREMATION CONTAiNEpi trau
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.
INVe understand that if the urn is too small to hold the entire cremated remains, an
used for delivery. additional rigid container may be
X- An um has not yet been purchased. Me understand that i
(cromaroryr�arn.} Pine View Crerllatory f no urn is purchased or otherwise provided
will place the cremated remains in a rigid temporary
container for delivery.
The Authorization Form was provided by(funeral director name)
was executed at(funeral home name)am Steven Duca
_
(funeral hams addroae) 98-07 Ascan Avenue. Fox Funeral Home, Inc.
Forest Hills NY 11375
as witness to its execution. and is signed by the funeral director
I/We have received a completed copy of this Authorization Form.
The persons) identified below is/are the persons)In control of disposition, who by signing this
Authorization Form, attests)to the accuracy and completeness of the information contained in this
Authorization Form and authorize(s)the foregoing.
Signed this 23rd day of Aril 20
Annaliza Del Rosario
Typed of Printed Name Si e
0-20 73rd Road Apt. 6G,Forest Hills,NY 11375
Address _
Typed or Printed Name Swat"
Address
TYPed Or Printed Name
Signature --.-_
Address —
WITNESS:
Steven Duca
Funerw DNector TYPed or P
ranted Name Funeral Director Signature _ _
14007
r?egistratton Number --
DOS-18M.f 1(Rev.01/1o) Kevin Be r Labe Del Rosario
Name of Deceased Page 3 of 3