Zapata, Fernando �4
Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME-,,�X RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: V-4-fi_0
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
NAME:-LCASE # 507
TYPE OF CONTAINER: : f/ JJO,<
PLACE OF DEATH: 4 /eA
ESTIMATED WEIGHT OF REMAINS & CONTAINER 40 269 l�-
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION: s i
TIME STARTED: 11•ID `ln TIME COMPLETED:
PLACED IN RETORT: ! MOVED: ��' 1 (Z.to
RETORT # IN WHICH REMAINS WERE CREMATED: SUQ�fZ �` K
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.
0NYS OrpNiomd of soft
Authorization for Cremation and Disposition pewem orc«■nrrr
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Theis Audmouhvftn Form must be completed and s/gned pdfor to delivery ofrwnalns for crsmovon.
Date: 05/01/20 Number:
Crematory Name: Pine View Ctanstory
Address: 21_Quaker Road,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 irate a
cremation chamber where they are subjected to Intense had and flame.The heat and fiance will incinerate and
Consume everything except bone and metal,which an all drat will be left after cremation.
Following cremation,the crematory will take reasonable efforts to remove an 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 wtp be mechanically,pulverized Into small pieces and placed into a
deslgabed contaksr or um.Cremated remains generally are pulverized until no simple f agment Is
recognisable 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 kW*of the deceased or to ensure that no material is enclosed which might injure employees or
damage a anrtstory property.If human remains are delivered in a container which is not suitable for cremation
such 111118 ceremonhd 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 wig be
conducted before a witness and will be dons in privacy,with dignity and respell.
IDENTIFICATION OF DECEASED
Name of Deceased:_Fernando Zapata Marital Status: Married
Last Known Address: 94-37 43rd Avenue,Elmhurst,NY 11373
Place of Death: Long Island Jewish Forest Hills, 102-0166th Road,Forest Hills,NY 11375
Sex: OM 13F Age: 65 DOB: 3/17/1955 Date of Death: 51M2020 Estimated Weight: 10 A,.
Descdption of caskeVcmWn er in which remains win be delivered:
Star Funeral Supply Wood container
PERSON IN CONTROL OF DISPOSITION
(Ferwn(s)/n COnbd of doperWn,IN ONE of Mo kilo*►')
I aril We are the designated agent of the deceased designated In a will or written Instrument executed
pinsuant to Public Health Law section 4201.
-OR-
,\44tM I/We have no knowledge that the deceased executed a written kntrurnerrt Wr uant to Public Heaffh Law
section 4201 or a will containing directions for the deposition of hia or her,remains and (Cw*wrd nW peer)
oos•re Fernando Zapata
ess+eaw.elrno► MrrwOfDw and Pao,r ova
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I @W*s are the peson(s)having priority,under Public Healdn Lan,sedan 4201 and have the right to authorize v
"nation of the remains of the deceased. MYMW relationship to the deceased is as follows:
(Inset fyom firs r at MOW
liurnb*r: 2 Desoripdorr: The stuvrvma spouse
1.A person designated in wri ft pursuant to Public Health Law secdon 4201(3); --
L The survf ft spouse;
2a,The surviving domestic pwbwr,
3.Any surviving Child eighteen years of sg*or older,
4.A surviving parent:
L A surviving siblkV eighteen years of age or older;
i.A bwfuny appointed guardian:
7•MY persorKs) 9~YOM of sge or older w&W to ahsro in the estate and who WMM closest In
roledansW to the deceased;
L A duly appointed f1dudary of the estate;
Y.A close Mend or relative who has executed a wrillan sfatensnt pursuant to Public Health Law§4201(7);
10.A chief ffsal ofliNcer of a county or a pulft for apPok"d pursuant to the Surrogates court
Procedure Ad;
10a.My other person who is soft on behaN of the deceased and who has execuled a written statement
Pursuant to Public Hesdh Law j42M1(7)
(lW ALL 7HREEo(tNs fbftft)
- 1.1.1 Wie hereby afMm that to body of the deceased doss not contain a battery,battery Pack power CM,
radioawve kVIRM.or redbadive device and that any such materials were removed prior to the execution of this
Audnorfzadon Form.Fallure to remove these hmne"Win"persomreL prior to cremation may resultresultin harm to the arernatory and
�./IIYVe hereby affirm that instructions have been given to mmwar.w. ,,) Staves Duce
regarding the removal of any Personal property or other thkV of value which any person signing below or any family member of the deceased wishas to preserve.(*W-$ y nwa) Pine view Gematory is not
responefbie for removal of Personal items from the container or from the remains of the deceased. Pgreonel Items
left in the container or with the remains will be destroyed by the
afbr crenwd n, cnematb brl
n process and cannot be rssved
��@ hereby suthorfre(a.,,,.m r, — Pine View
ss (;rcm�*o*v to cremate the
remains of the deaeed,
t7NAL DISPOSITIfJN
The Person sudar(zed to receive the cremated remakes of the deceased from the crematory is:
Nam*: Fox Funeral Home Inc,
Address: 9847 Ascan Avenue Forest Hills NY 11373 Phone:-(718)268-7711
The cremated remains of deceased will be disposed of as follows:
Yet to be ddermined
if for any maser the pion named above dose not take possession of the cremated remains,
Ow-ftynawl Pine View nxnMM is authorized to give Possession of the remakes to
OUMNtA M M M) Pox Funeral Home Inc, by delivery In Person or by registered Mel.
Dos.nsaM MOV1 onnq Fernando Zapata
NW*OfDaaawad vas:2 of�
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1Affls rrn rim rstannd ghat N the remains are not dairrned within 120 days of cromatlon,
jb ob) Pine view cxmstaff may dispose of the remains in an irretrievable mamer,
such as by scatoerinp.
MW ONE o(Vw bm owrrp)
An um to be used as a corftkw for the cremated remains has been purchased from
Fox Funeral Home.Inc. and is desuibed as follows:
tMlb undo, to that if the um is too Ong to hold the entire cremated rematrns,an add tlormd rVd Container may be
used far delivery.
M. An um has not yet been ptrdmW, UWb urnderstaarnd that N no um is ptrdnased or otlnerwise provided
(aa mb)no'y Pine View Cmmatory will plaCs the cremated remains in a rigid temporary
=dakw for detavery.
The AWwftodon Forth was provided by PkMW.*vena►nm,) Steven Duca
was e:oeaited at Aaw,r ham rm o Fox Ftmcml Home.Inc.
� on.o e aaanst 9tt-07 Ascan Avenue Fored H'1% NY 11375 and is signed by the funeral director
as witness to ib mocubom
M%have nowhod a eornOded copy of this Authorization Form.
The psraon(s)ldsntillad below b)am the persons)In control of dispostdon,who by signing a"
Authorization Form,atbet(s)to the acmrsey and compbtsrtess of the Information contained in th(s
AudwrbM m Form and audmwke(s)the foregoing.
Signed this 1st day of May .20 20 .
Teresa Canino _
Tina F1li1r0Arr� OWN"
94.37 43rd Avemne. ,NY 11373
anUMM
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Add�ses
71'PbwAlrielUrrdrr �n
Addnrsi
Steven Duca
POMWDr rlMWGrPM*dNrn� FirMril0i�cfor ,(/nC.�
14007 "'
aY�M�Ababrr
Cos less4r0Wv OM Fe:eumdo Zapata
hen,,.oomora .O
vao.sae
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