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Das, Jharna 50e Pine View Cemetery & Crematorium Quaker Road Queensbury, NY 12804 (518) 745-4477 or (518) 745-4476 FUNERAL HOME:.A,���I, RETURN TIME: DATE & TIME REMAINS ARRIVED AT CREMATORY: 5I5I2-0 /0.3 D NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS: �n NAM E`er I!'GiL�t /pa4 CASE # Ll TYPE OF CONTAINER: A" PLACE OFJ"(_ !5 DEATH: .3 ESTIMATED WEIGHT OF REMAINS & CONTAINER 6/51ZO PLACED IN HOLD: PLACED IN REFRIGERATION: It 00 DATE OF CREMATION: 8 I S I Zz TIME STARTED: Z O6M TIME COMPLETED: -� PLACED IN RETORT: 2`"��1�► ' 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. Authorization for Cremation and Dis/^�osition 5 NYS Department of State N Division of Cemeteries One Commerce 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: 05/01/20 Number: 50g Crematory Name: Pine View Crematory Address: 2.1 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 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: Jharna Das Marital Status: Widowed Last Known Address: 106-20 70th Avenue Apt.4A, Forest Hills NY 11375 Place of Death: Long Island Jewish Medical Center. 27005 76th Avenue New Hyde Park, NY 11040 Sex: ❑M OF Age: 79 DOB: _ 10/30/1940 Date of Death: /30/2020 stimated Weight: f a10 Description of casket/container in which remains will be delivered: Wood container(Star Funeral Supply) PERSON 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 pursuant to Public Health Law section 4201. -OR- �< I/NNe 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) Jharna Das DOS-1898-f-I(Rev.01110) Name of Deceased Page 1 of 3 I am/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: (Insert from the list below) Number: 3 Description: >7 , Uvviu;v 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 §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 ALL THREE of the following) '- K.P 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 N % _ I/We hereby affirm that instructions have been given to (funeral director name) Steven Duca 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. �K D IMe hereby authorize(crematory name) Pine View 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 11375 _ Phone: (718) 268-7711 The cremated remains of deceased will be disposed of as follows: Yet to be detemined 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. Jharna Das DOS-1898-f-I(Rev.01110) Name of Deceased Page 2 of 3 (Initial the following) X1 0 Me understand that if the remains are not claimed within 120 days of cremation, (crematory name)_ Pine View Crematory may dispose of the remains 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 purchased from Fox Funeral Home Inc. and is described as follows: INVe understand that if the urn is too small to hold the entire cremated remains, an additional rigid container may be used for delivery. -OR- '� I(D An urn has not yet been purchased. INVe understand that if no urn is purchased or otherwise provided (crematoryname) ,—___ — _Pine View Crematory _ -_ will place the cremated remains in a rigid temporary container for delivery. The Authorization Form was provided by (funeral director name) Steven Duca Was executed at (funeral home name) Fox Funeral Home, 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 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 1st day of May , 20 20 . Kasturi Das �-_ Ll -t-u�i Typed or Printed Name Signature 106-20 70th Avenue Apt. 4A, Forest Hills,NY 11375 Address Typed or Printed Name — Signature Address Typed or Printed Name Signature Address — WITNESS: __-- Steven Duca Funeral Director Typed or Printed Name Funeral Director Signature 14007 Registration Number Jharna Das DOS-1898-f-I(Rev.01110) Name of Deceased Page 3 of 3