Fiel, Maxine Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: Of
REQUESTED RETURN TIME:
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
NAME:
Awx
CASE fl
DATE OF CREMATION:
TIME STARTED;
- - TIME COMPLETED.
.... .... ....
TYPE OF CONTAINER:
ACED IN RETORT:
PLACE OF DEATH: ....
.......... _ __
ESTIMATED WEIGHT OF REMAINS AND CONTAINER:
DATE & TIME REMAINS ARRIVED AT CREMATORY:
PLACED IN HOLD:
PLACED IN REFRIGERATION:
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 0F THE CREMATORY.
„ . New York State
Department of State
NEW YORK Division of DIVISION OF CEMETERIES
STATE OF One Commerce Plaza
OPPORTUNITY. Cemeteries
99 Washington Avenue
Albany,NY 12231-0001
Telephone:(518)474-6226
www.dos.ny.gov
Authorizaiioii For Greriaticr ane, Disposition
This Authorization Form must be completed and signed prior to delivery of remains for cremation.
Date:
4/25/2020 t13 q
!vumber: I J
Crematory Name:
Pine View Crematory
Quaker Road, Queensbury, NY 12804 518-745-4477
Address: Phone:
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation is carried out by pla.ing 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 wfir 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 arr'the l c de^ta' and foreign material will be disposed of as required by law. The cremated remains will be mechanically
pulverized into small nieces 2-nd placed into a designated container or urn. Cremated remains generally are pulverized until no
single fragment is recognizable as skeletal tissue.
OPENING OF THE 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 er to ensure that no material is enclosed which might injure employees or damage the crematory property. If
hum na:an rerins ara d-.i •,, ra^! it a container lmhich is not suitable for cremation.such as ceremonial or rental ?.sket, the
cremato\,w0l' .•eru;r^+' t t"e remains be rr.cved into a suitable container before it accepts the remains. The opening of a
container or the trans” ~cr r emeval of remains ,vill be conducted before a witness and will be done in privacy, with dignity and respect.
IDFNTIF!CA.T!QR OF DECEASED
Name of Deoeaz;e- Marital S±atlas:
%1 ia,ren St GI^rs =2!IS NY 12801
Las`Kno<n,�,,=.da�ess
PIaCn O`7"2.a i is Fall,, Hospital, Glens Falls, NY 12801
Sex: C >.' _ D`' _ DOB: 5/30,%1923 Date of Death: 4/25/2020 Es,,.._ated\^!eight:
De5crjpdo:. O C:S;. `f o r, - -hlch remains Nlll be delivered
Wood Lcttc:': ,rt;� t,on containei
PF2SD+ `1 ''` R' OF pi'.SPOSITION
(Person(s) in control�f c o ion initial ONE of the following)
----- -- 1 -m",NP r==;,e '�q nnated anent of the deceased designated in a will or written instrument executed pursuant to Public
Health La,. _ c yr�
i
i'W 3 -av� Kncr, ledge that the aeceased executed a written instrument pursuant to Public Health Law Section 4201 or a
will contain na T-,,+:r.- Iisposition of hl;or her remains end I/we are the person(s) having pr�cr!t�,1andcr Public Health Law
e iC r to authorize cremation of the remains of the deceased. My/Our relationship to the deceased is as
follows:
Maxine Fiel
(Name of Deceased)
D' - 3', �g e . cf 3
A1Ahor;_7a'_'1.,,,. 'c ' ramation -Ind Disposition
Initial the f ww 9)
Me understand t'.at if the remains are not claimed within 120 days of cremation,
;rr
mav dispose of tha remains in
Name of Crematory)
an irretrieva5le manner. such as by scattering.
CREMATION CONTAINER/URN
(jQLi,i'qI ONE
_-Sec) L a container for he cremated remains has been purchased from
and is described as f61ows:
I/We unde.rst2r,: jrr, s too small to hold the entire cremated remains, an additional rigid container may be used for delivery.
An um is r:,t yet purchased. I/We understand that if no urn is purchased or otherwise provided
will place the cremated remains in
(Name of Crematory)
a rigid temporary container for delivery.
Patricia Miller
This Authorizarico in .vas orovided by was executed at
(Funeral Director Name)
Brewer Fum�,_ me, !,,�C.
24 Church St., 1-ake _uzerne, NY 12846 Funeral Horric Name)
limp q'J Home Address)
anc is sicF cl;-
�ctor as witness to its execution.
Me have rece:ve� 2. c,=,2!eted copy of this Authorization Form.
Thv persancs. _-c. belo.,v is/are the person(s) in control of disposition,who by signing this Authorization Form, attest(s)
to the accuracy and c^moleteness of the information contained in this Authorization Form and authorize(s)the foregoing.
April 20
Signed to day of
51.1 YorK (--,Ir
Address
Signature
Tur!
T YDP:! Signature
Aoorass
P C,2
(Funeral Director Signature
1"'465
Maxine Fiel
IF L'�
r E; Page 3 of 3
�- - :
Authorization for Cremation and Disposition -"'—
(Insert from the uSt below)
3 daughterNumber: 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 parem'
5. 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 cf the estate;
9. A close friend or relative who has executed a written statement pursuant to Public Health Law Section 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 Section 4201(7).
(Initial ALLY THREE of the following)
-" 1/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.
Patricia Miller
I/We affirm that instructions have been given to
(Funeral Director Name)
regarding the removal of any personal property or other thing of value which any person signing below or any family member of the
Pine View Crematory
deceased wishes to preserve.
(Crematory Name)
is not responsible for the 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.
Pine View Crematory
hereby authorize
(Crematory Name)
to cremate the remains of the deceased.
FINAL DISPOSITION
The person authorized to receive the cremated remains of the deceased from the crematory is:
Brewer Funerai Home, Inc.
Name:
24 Church St., Lake Luzerne, NY 12846 518-696-2744
Address: Phone:
The cremated remains of deceased will be disposed of as follows:
returned to Meredith
If for any reason the person named above does not take possession of the cremated remains,
Pine View Crematory
is authorized to give possession of
(Crematory Name)
Brewer Funeral Home, Inc.
the remains to by delivery
(Funeral Home Name)
in person or by registered mail.
Maxine Fiel
(Name of Deceased)
DOS-1898-f(Rev. 08/15) Page 2 of 3