Michel, Lawrence Robert Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: Nev(Q-,C, Y erp-&IA� RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: ��"2g"2-0 Zo 34101pw1
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
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NAME: _ � �' r�nL ��d�d/� I�YI i j `Q CASE #
TYPE OF CONTAINER: err' "r1�e 6c'eroa-/�,, (.Grtfi
PLACE OF DEATH: A)4-12 � ��>> n �, �'✓1�C��G.tt L',�(�' I7'►�ne� 2Z�jl,1i� S
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ESTIMATED WEIGHT OF *REMAINS & CONTAINER 7U /'�+ S S'e-e lej -Z 9/6s
PLACED IN HOLD: .l45�r''�
PLACED IN REFRIGERATION:
DATE OF CREMATION: Zj ,29 - 20 2C)
TIME STARTED: _i-3o p z-. TIME COMPLETED:
PLACED IN RETORT: MOVED: vJ ri
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.
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New York State
NEW YORK Department of state
STATE OF
Division of DIVISION OF CEMETERIES
OPPORTUNITY. One Commerce Plaza
Cemeteries 99 Washington Avenue
Albany,NY 12231-0001
Telephone:(518)474-6226
www.dos.ny.gov
Authorization for Cremation and Disposition
This Authorization Form must be completed and signed prior to delivery of remains for cremation.
Date: 04/24/2020
Number:
Crematory Name: Pineview Crematory
Address: 21 Quaker Rd, Queensbury, 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 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 or to ensure that no material is enclosed which might injure employees or damage the crematory property. If
human remains are delivered in a container which is not suitable for cremation such as 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: Lawrence Robert Michel Marital Status: Married
Last Known Address: 523 E. Pine Street,Lower Unit, Long Beach, NY, 11561
Place of Death: Nassau County Medical Examiner, 2251 Hempstead Turnpike- Building R, East Meadow, NY, 11554
Sex: ®M 1 F Age: 67 DOB: 06/28/1952 Date of Death:__y/J `L �' Estimated Weight: 170
Description of casket/container in which remains will be delivered.
Alternative Cremation Container
PERSON IN CONTROL OF DISPOSITION
(Person(s)in control of disposition, initial ONE of the following)
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 I/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:
New Leaf Cremation Lawrence Robert Michel
Michel, Lawrence (Name of Deceased)
DOS-1898-f(Rev.08/' TR042520_FH11/CO5/039 Page 2 of
Authorization for Cremation and Disposition
(Insert from the list below)
Number: 3 Description: Brother
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;
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 of 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 ALL THREE of the following)
-2C I/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.
�C I/We affirm that instructions have been given to Michael Noll
(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
deceased wishes to preserve. Pineview Crematory 21 Quaker Rd, Queensbury, NY 12804
(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.
PC I/We hereby authorize Pineview Crematory 21 Quaker Rd, Queensbury, NY 12804
(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:
Name: Donald Clarfeld
Address: 2595 Juanita Way, Laguna Beach, CA, 92651 Phone: 949-246-1154
The cremated remains of deceased will be disposed of as follows:
Cremation
If for any reason the person named above does not take possession of the cremated remains,
Pineview Crematory 21 Quaker Rd, Queensbury, NY 12804 is authorized to give possession of
New Leaf Cremation (Crematory Name)
the remains to by delivery
(Funeral Home Name)
in person or by rel New Leaf Cremation
Lawrence Robert Michel
Michel, Lawrence
TR042520—FHII/C05/039 (Name of Deceased)
DOS-1898-f(Rev Page 3 of 4
Authorization for Cremation and Disposition
(Initi I the following)
I/We understand that if the remains are not claimed within 120 days of cremation,
Pineview Crematory 21 Quaker Rd, Queensbury, NY 12804
may dispose of the remains in
(Name of Crematory)
an irretrievable manner, such as by scattering.
CREMATION CONTAINER/URN
(Initial ONE of the following)
An urn to be used as a container for the cremated remains has been purchased from
and is described as follows:
I/We understand that if the urn is too small to hold the entire cremated remains, an additional rigid container may be used for delivery.
-Off �
►��"— An urn is not yet purchased. I/We understand that if no urn is purchased or otherwise provided
Pineview Crematory 21 Quaker Rd, Queensbury, NY 12804 will place the cremated remains in
(Name of Crematory)
a rigid temporary container for delivery.
This Authorization Form was provided by Michael Noll was executed at
New Leaf Cremation (Funeral Director Name)
3930 Long Beach Rd., Island Park, NY 11558 (Funeral Home Name)
(Funeral Home Address)
and is signed by the funeral director as witness to its execution.
I/We have received a completed copy of this Authorization Form.
The person(s) identified below is/are the person(s) in control of disposition,who by signing this Authorization Form,attest(s)
to the accuracy and completeness of the information contained in this Authorization Form and authorize(s)the foregoing.
Signed this 22 day of April ,20 20
Donald Clarfeld
Typed or Printed Name Signature
2595 Juanita Way,Laguna Beach,CA,92651
Address
State of
County of
The foregoing document was acknowledge before me this#3 day of 202_by who personally appeared who proved to me
on the basis of satisfactory evidence to be the person(s)whose name(s)is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the
same in his/her/their authorized capacity(ies),and that by his/her/their signature(s)on the instrument the person(s),or the entity upon behalf of which the person(s)acted,
executed the instrument
Notary Signature
Notary Stamp(frequently call the seal)
WITNESS:
Michael Noll
(Funeral Dire cr Typed or nted Name) (Funeral Director Signature)
pn
(Registration ivumr
New Leaf Cremation
1'0 0
Michel, Lawrence „.,.,y , , A
T11042520_FH11/C05/039 (Name of Deceased)
DOS-1898-f Page 4 of 4