Zhang, Chen Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: r ", .(/lfoit D V� RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: � � 4�LQL2��•
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
,.Z--JlM �`C "4-ff-
NAME: 9F-k, 2&nd CASE #� �
TYPE OF CONTAINER:
PLACE OF DEATH: wld / l�4kzzej
ESTIMATED WEIGHT OF REMAINS & CONTAINER
PLACED IN HOLD: � �(1(0
PLACED IN REFRIGERATION:
DATE OF CREMATION: q��I
TIME STARTED: Iti TIME COMPLETED:
PLACED IN RETORT: � ' 1 MOVED: Zs l-r� /: O Pt)
RETORT # IN WHICH REMAINS WERE CREMATED: okit
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 DispositionD WPM Of C4"Wkm
qee conrrwoe w.:s.99 waah.gton Aven,e
Al arty,NY,net
(518)4744 5M
www dos sta s ny.us
This Authorizatlon Form must be completed and signed prior to delivery of rwnalns for cremation.
Date. April 26",2020 Number. 'C6 Z—
Crematory Name: Pine View Crematory
Address: 21 Quaker Road,Queens NY 12804 Phone: (519)745-4476
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 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 puiverized 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: Chen Zhang Marital Status: Married
Last Known Address: 4005 12th St.Apt.3C,Astoria,NY 11101
Place of Death: Mouat Sinai Hospital Of Queens.,Astoria,NY 11103
Sex: ❑M ®F Age: 71 DOB: 3/24/1949 Date of Death: 4/24/2020 Estimated Weight:
Description of casket/container in which remains will be delivered:
Wood and Cardboard cremation container
PERSON IN CONTROL OF OISPOSITION
(Aerson(s)in control of d* ,n iel OME of Uie ft#D* V)
I am/We are the designated agent of the deceased desprmted in a will or written utstrunwtt execuad
pursuant to Public Health Law section 4201.
-OR-
_ WVs have no knowledge that the deceased executed a written itrtunem pursuant to public I WO Low
section 4201 or a will containing directions for the disposition of his or her remains and (Ccr,d►,,,b„ /
Chen ZhMg
cos-18a44(Rw.OtnO) Ante dnecoesW pNpe 1013
I am/we are the persons having
cremation of the remains of the eceased. MY/Oulr relationship tic Health Low section
the deceased Is as follows:s to authorize 06
r Insert fia,»the list below)
Number: 3 Description: Surviving Child
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 no or older,
4.A surviving parent;
S.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 n the estate and who is/are closest in
relationship to the deceased;
I.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 app nted 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)
(NO-1 LL THREE of the following)
- Lx�radioactive implant, or radioactive device and that any such m INVe hereby affirm that the body of the deceased does
Authorization Form. Failure to remove the not contain a battery, battery pads, power cell,
aterials were removed prior to the execution of this
se items prior to cremation may result In harm to the crematory and
crematory personnel.
_J26L_ UWe hereby affirm that instructions have been given to(lun"dkedorneme) Thaddeus W. Baxter
regarding the removal of any personal property or other thing of value which an
member of the deceased wishes to preserve. (crematory Hemel Pine Viewer
iew Crematory son signing below or any family
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(crwnek y„Nft)_ Pine View Cremato
ry
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 Ph (718)268-
Phone: 7711(fd(1747 RSSS
The cremated remains of deceased will be disposed of as follows:
If for any reason the person named above does not take possession o`1 the cremated remains,
(aw"OklynWW) Pine View Crematory is authorized to give possession of the remains to
Aiune home rwm) Fox Funeral Home Inc. by ;delivery in person or by registered mail.
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DOS-100944(Rev.01/10) then ZhangaDem
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Pepe 2 or 3
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IMe understand that if the remains are not claimed within 120 days of cremation, v
(Ow"tay'anw) Pine VieWC a may dispose of the remains in an irretrievable manner,
such as by aoattenng.
CREMATION CONTAIN RA IRY
g E of the following)
An um to be used as a container for the cremated remains has been purchased from
and is described as follows:
11We understand that if the um is too small to hold the entire c rem used for delivery. at ' remains, an additional rigid container may be
-OR-
--49A _ An um has not yet been purchased. INVe understand that no um is
(aamatay" r") Pine View Crematorypurchased or otherwise provided
container for delivery. will place the cremated remains in a rigid temporary
i
The Authorization Form was provided by 1A,nefateY/a�t,,,N,,1e) Thaddeus W. Baxter
was executed at(&ww Nome norms)
M"°r'l ham+MM") 98-07 Ascan Avenue Forest Hills NY 11375eral HomandInc signed by the funeral director
as witness to its execution.
Me have received a completed copy of this Authorization Form.
The Person(s)identified below is/are the person(*)In control of disposition,who by signing this
Authorization Form,attests)to the accuracy and completeness bf the information contained In this
Authorization Form and authorize(*)the foregoing.
I
Signed this 25th day of Aard
ZO .
ion ei Ni (Michelle) X
TiPed or"Mfed Meme
6802 150th St. Kew Gardens Hills NY 11355
7 Address
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Address
WITNESS:
Thaddeus W.Baxter L
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Funeral Dhclgr Typed or P�irMbd Avrne
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