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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 C 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. w 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