Weaver, Kim Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: NF WIALM RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: S/I I -m ID' 30ft
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
F u5 j YTEQ
NAME: CASE # `7 D
TYPE OF CONTAINER: 544('
PLACE OF DEATH: Pool LN go (L% G/ 76
ESTIMATED WEIGHT OF REMAINS & CONTAINER
PLACED IN HOLD: ! 10 /`flrl
PLACED IN REFRIGERATION:
DATE OF CREMATION:
TIME STARTED: 16 t-1 TIME COMPLETED: N DAM
PLACED IN RETORT: ��30 _MOVED:
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.
DocuSign Envelope ID:C28C57FO-OA34-48B7-8BD4-AO5039C5D2FC
,riumufadtion Tor cremation and Disposition NYS Departrnent of Stat
Division of Cemeterie
One Commerce Plaza,99 Washington Avenu
Albany,NY 1223
(518)474-6221
www.dos.state.ny.ui
This Authorization Form must be completed and signed prior to delivery o remains for cremation.
Date: 4/22/2020 Number: g
Crematory Name: Pine View Cemetery & Crematorium
Address: 21 Quaker Rd, Queensbua Hamlet, 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 hol ling the remains into a
cremation chamber where they are subjected to intense heat and flame. The heat anc flame will incinerate and
consume everything except bone and metal, which are all that will be left after c emation.
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 materia will be disposed of as
required by law. The cremated remains will be mechanically pulverized into small piec s and placed into a
designated container or urn, Cremated remains generally are pulverized until no si rigle fragment Is
recognizable as skeletal tissue.
OPENING OF CONTAINER.
The crematory may only open the container holding the un-cremated human remains in imited circumstances, such
as to confirm the identity of the deceased or to ensure that no material is enclosed whicl might injure employees or
damage crematory property. If human remains are delivered in a container which is lot 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: Kim WeaverMarital Status: Divorced
Last Known Address: 130 Moore Street, Apt. 9G, Brooklyn, NY 11207
Place of Death: Woodhull Hospital, , Brooklyn. NY 11207
Sex: ❑M QF Age: 57 DOB: 10/26/1962 Date of Death: 4/15/2020 Estimated Weight: 175
3escription of casket/container in which remains will be delivered:
Alternative Cremation Container, Wood base, Cardboard top, Star MFG.
DERSON IN CONTROL OF DISPOSITION
Person(s)in control of disposition, initial ONE of the following)
I am/We are the designated agent of the deceased designated in a will or written instrument executed
)ursuant to Public Health Law section 4201.
PROS
I/We have no knowledge that the deceased executed a written instrument purst liant to Public Health Law
4201 or a will containing directions for the disposition of his or her remains and Continued next page)
Kim Weaver
0S-1898-f-I(Rev.01/10) Name of Deceased Page 1 of 3
DocuSign Envelope ID:C28C57FO-OA34-48B7-8BD4-AO5039C5D2FC
1 am/we are the person(s) having priority under Public Health Law section 4201 and hai a the right to authorize
cremation of the remains of the deceased. My/Our relationship to the deceased is i s follows:
(Insert from the list below)
Number: 3 Description: Child of Kim Weaver
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 v rho 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 tot ie Surrogate's Court
Procedure Act;
10a. Any other person who is acting on behalf of the deceased and who has execuled a written statement
pursuant to Public Health Law§4201(7)
W ALL THREE of the following)
10 I/We hereby affirm that the body of the deceased does not contain a battery, b ttery pack, power cell,
r dive implant, or radioactive device and that any such materials were removed pric r to the execution of this
Authorization Form. Failure to remove these items prior to cremation may result in ianin to the crematory and
=@tnatory personnel.
PW I/We hereby affirm that instructions have been given to (funeral directorname) Danford S.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 Cemete Crematorium is not
responsible for removal of personal items from the container or from the remains of the eceased. Personal items
left in the container or with the remains will be destroyed by the cremation process;and cannot be retrieved
scremation.
P� I/We hereby authorize(crematory name) Pine View Cemetery& Crematorium to cremate the
s of the deceased.
FINAL DISPOSITION
The person authorized to receive the cremated remains of the deceased from the cremat ry is:
Name: Patrice Weaver C/O N.F. Walker, Inc. 2039 Merrick Ave. Merrick NY 11566
Address: 7596 Lorimar Drive, Reynoldsburg, OH 43068 hone: (614)255-8497
Fhe cremated remains of deceased will be disposed of as follows:
Yet to be determined
f for any reason the person named above does not take possession of the cremated rerr ains,
crematory name) _ Pine View Cemetery & Crematorium is authorized to give possession of the remains to
Funeral home name) N. F. Walker Inc. by delivery in person or by registered mail.
Kim Weaver
)OS-1898-f-I(Rev.ovio) Name of Deceased o..
DocuSign Envelope ID:C28C57FO-OA34-48B7-8BD4-AO5039C5D2FC
l the following)
I/We understand that if the remains are not claimed within 120 days of cremation,
name) Pine View Cemetery & Crematorium may dispose of the rem 3ins in 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 purchas ad from
N. F. Walker Inc. and is described as follows:
I/We understand that if the urn is too small to hold the entire cremated remains, an add ional rigid container may be
used for delivery.
g
P� An um has not yet been purchased. I/We understand that if no urn is purchalq ed or otherwise provided
(crematory name) Pine View Cemetery& Crematorium will place the cremated i emains in a rigid temporary
container for delivery.
The Authorization Form was provided by (funeral director name) Danford lko. Baxter
was executed at (funeral home name) N. F. Walker, Inc., VIA DocuE i
gn
(funeral home address) 2039 Merrick Avenue, Merrick NY 11566-3434 and is s gned 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 islare the person(s) in control of disposition, who I ly signing this
Authorization Form, attest(s)to the accuracy and completeness of the informatloi i contained in this
Authorization Form and authorize(s) the foregoing.
Signed this 22nd day of 4/22/2020
April 20 20 .
�'.C.U'A.""'F2E
Patrice Weaver
Typed or Printed Name Signature BB...
7596 Lorimar Drive Re noldsbur OH 43068
Address
Towanna Weaver
Typed or Printed Name Signature
130 Moore St. , 9G Brooklyn NY 11566
Address
William Weaver
Typed or Printed Name Signature
3 Wayne Dr., Dover Plains NY 12522
Address
VITNESS:
Sanford S. Baxter
°uneral Director Typed or Printed Name Funeral Director igna re ;
0225
tegistration Number
Kim Weaver
►OS-1898-f-I(Rev.oulo) Name of Deceased Page 3 of 3
DocuSign E�vi elope ID: lD693995-220B-4C4A-8B52-E014B6241689
1 ht;=rstand that if the remains are not claimed within 120 days of cremati
(crematory name) Pine View Cemetery & Crematorium may dispose of the remai is in an irretrievable manner,
such as by scattering.
CREMATION CONTAINERMRN
'initial ONE of the following)
An urn to be used as a container for the cremated remains has been purchase from
N. F. Walker, Inc. and is described as follows:
I/We understand that if the urn is too small to hold the entire cremated remains, an addition al rigid container may be
used for delivery.
M� urn has not yet been purchased. I/We understand that if no urn is purchas d or otherwise provided
(crematory name) Pine View Cemetery & Crematorium will place the cremated rt mains in a rigid temporary
container for delivery.
The Authorization Form was provided by (funeral director name) Danford S Baxter ,
was executed at(funeral home name) N. F. Walker Inc. VIA DocuS gn ,
(funeral home address) 2039 Merrick Avenue, Merrick,NY 11566-3434 and is si ned 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 22nd day of April , 20 20
Patrice Weaver
Typed or Printed Name Signature
7596 Lorimar Drive, Re noldsbur , OH 43068
Address
Towanna Weaver
Typed or Printed Name Signature
130 Moore St. , 9G Brooklyn NY 11566
Address
DocuSigned by:
William Weaver
Typed or Printed Name Signature 915598ECOCOD46F...
8 Wayne Dr.,Dover Plains,NY 12522
Address
NITNESS:
Danford S. Baxter
Funeral Director Typed or Printed Name Funeral Director * ature
10225
Registration Number
Kim Weaver
DOS-18984-1(Rev.01110) Name of Deceased Page 3 of 3
DocuSign Envelope ID:34823127-3BEF-4396-8C72-34796DC19567
the following)
_[2�e understand that if the remains are not claimed within 120 days of crema on,
(crematory name) Pine View Cemetery& Crematorium may dispose of the rem 3ins in an irretrievable manner,
such as by scattering.
CREMATION CONTAINERIURN
(Initial ONE of the following)
An urn to be used as a container for the cremated remains has been purchas ad from
N. F. Walker Inc. and is described as follows:
I/We understand that if the urn is too small to hold the entire cremated remains, an add ional rigid container may be
used for delivery.
um has not yet been purchased. I/We understand that if no urn is purchac.ed or otherwise provided
cremawry name) Pine View Cemetery& Crematorium will place the cremated emains in a rigid temporary
container for delivery.
The Authorization Form was provided by (funeral director name) Danford . Baxter
was executed at (funeral home name) N. F. Walker Inc. VIA Docu i n
(funeral home address) 2039 Merrick Avenue Merrick NY 11566-3434 and is gned by the funeral director
as witness to its execution.
I/We have received a completed copy of this Authorization Form.
The persons) identified below is/are the person(s) in control of disposition,who y signing this
Authorization Form, attest(s)to the accuracy and completeness of the informatio contained in this
Authorization Form and authorize(s)the foregoing.
Signed this 22nd day of April 20 20
Patrice Weaver
Typed or Printed Name Signature
7596 Lorimar Drive, Re noldsbur OH 43068
Address
DocuSigned by:
Towanna Weaver
Typed or Printed Name Signature
85CA74ASFFCF48D...
130 Moore St. , 9G, Brookl n NY 11566
Address
William Weaver
Typed or Printed Name Signature
B Wayne Dr. Dover Plains NY 12522
4ddnsss
WITNESS:
Danford S. Baxter
-unera/Director Typed or Printed Name Funeral Direct Si na
10225
2egistration Number
Kim Weaver
>OS-1898-f-1(Rev.01/10) Name of Deceased Paoe 3 of 3