Anolin, Myrna V. Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: 60X T,,-v C Roor� RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: (Th f IQ ID;-�Q Atl
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
NAME: NRM. CASE # `7
TYPE OF CONTAINER:
PLACE OF DEATH: 107-01 61 1�I 41lls
ESTIMATED WEIGHT OF REMAINS & CONTAINER
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION: / r Z.®
TIME STARTED: Zp TIME COMPLETED: �l J 10pt-,�-j
J
PLACED IN RETORT: � MOVED: �3 �n'1
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.
Authorization for Cremation and Disposition NYS Department of State
Division of Cemeteries
One Commeroe 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: April 27th, 2020
Number: y1�
Crematory Name: _Pine View Crematory
Address: 21 uaker Road
Q _ , Queenshury,NY 12804 Phone: (518�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 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: Myrna V. Anoiin Marital Status: Never Married
Last Known Address: 175-20 Wexford Terrace Apt. 5X, Jamaica,NY 5
Place of Death: Long Island Jewish Forest Hills, 102-01 66th Road, Forest Hills, NY 11375
Sex: ❑M OF Age: 75 DOB: 8/21/1944 Date of Death: 4/27/2020_ Estimated Weight: 125lbs
Description of casket/container in which remains will be delivered:
Wood and Cardboard cremation container f�'� FN�✓P�'L �u�/�'�
PERSON IN CONTROL OF DISPOSITION
(Person(s)in control of dispositia , inifia! NE 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-
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)
Myrna V. Anolin
DOS-1898-f-I(Rev.01110) Name Ot Deceased Page 1 of 3
f am/we are the person(s) having priority under Public Health Law section 4201 and have the right
cremation of the remains of the deceased. My/Our relationship to the deceased is as follows:to authorize
(Insert from the list below)
Number: S Description: Surviving Sibling at least 18 yrs of are
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;
S.A surviving sibling eighteen years of age or older;
6.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;
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)
(Initial L THREE of the following)
lNVe 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
re
crematory personnel.
L (/We hereby affirm that instructions have been given to(funeral director name) Thaddeus W. Baxter
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
after cremation.
Y U. I/We hereby authorize(crematofy name) Pine Vicw 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 1 I375 (718)268-
_ __ Phone: _ZZl 1 rr;n3 i a3R-F371
The cremated remains of deceased will be disposed of as follows.
To be taken to the Philippines for Burial
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
(funeral home name) Fox Funeral Home, Inc. by delivery in person or by registered mail.
DOS•1898-f-I(Rev.01I10) Myrna V- AnolinName of Deceased
Page 2 of 3
•
(lniti I the following)
L INVe understand
tend that if the remains are not claimed within
(crernat as byname)scattering. 120 days of cremation,
such as by may dispose of the remains in an irretrievable manner,
CREMATION CONTAINERIURN
(Initial 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:
I/We understand that if the um is too small to hold the entire cremated r
used for delivery_ emains, an additional rigid container may be
� R- - A
n urn has not yet been purchased. INVe understand that if no urn is purchased or otherwise provided
(crematory name) Pine View Crematory will place the cremated remains in a rigid temporary
container for delivery.
The Authorization Form was provided by(funeral director name) Thaddeus W. Baxter
was executed at (funeral home name) Fox Funeral Name, Inc.
(funeral Home address) 98-07 Ascan Avenue, Forest Hills,NY 11375 and is signed by the funeral director
as witness to its execution.
INVe have received a completed copy of this Authorization Form.
The person(s) identified below islare the person(s) 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 27th day of April , 20 20
Daisy Anolin Langley _ X
Typed or Printed Name Signature
1 Regency Village Way Apt. 2U8, Merrimac, MA 01860
Address
Typed or Printed Name
Signature
Address -
Typed or Printed Name
Signature
Address
WITNESS: '
Thaddeus W. Baxter
Funeral Director Typed or Printed Name Funi ral Director Signature
10227
Registration Number
Myrna.V. Anolin
DOS-1898-f-I(Rev.01/10) Name of Deceased
Page 3 of 3