Graham, Clarise Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME:
V` 5 RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: 5`r7' ZD - I • 5bPk--k
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
NAME: CASE #
TYPE OF CONTAINER:
PLACE OF DEATH:
ESTIMATED WEIGHT OF REMAINS & CONTAINER r l �� �Gc��� 15-7 Ibs
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION: �- 7-20 20
TIME STARTED: TIME COMPLETED:
PLACED IN RETORT: 1--/I ZP l 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.
May 0$20,03:33p p.1
ate
Authorization for Cremation and Disposition Division of Cem�eteriies
One Commeroe Plaza,99 Washington Avenue
Albany,NY 12231
(518)474-6226
wwwAos.state.ny.us
This Authorization Form must be completed and signed prior to delivery of remains for cremation.
Date: 5 l I o 6 2,d Number: ��7
Crematory Name: Pine View Crematorium
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 um. 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: CLAWS GRAVAAM Marital Status: SIN GL F,
Last Known Address: u1Q4 1 TK STILT' LTC- ray 10
Place of Death: 9"V-1.1 IAA (R.C4101�SO
Sex: 17M 5?F Age:r!� DOB: -1-aO -19coli tate of Death: ("{•�a-26R0 Estimated Weight: t JS'
Ibs
Description of casketicontainer in which remains will be delivered:
Alternative Container CARD'GARD
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-
(Z,G _ 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 (Continued next page)
Qn M SE. GRAHAM
DOS-189844 (Rev.01110) Name of Deceased Page 1 of 3
May 05 20,03:33p p,2
1 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: t)AV&KTE(Z
I.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;
&A surviving sibling eighteen years of age or older;
S.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;
&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 SurrogaWs 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).
(JaWW A11 THREE of the following)
C lMe 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 C7 Me hereby affirm that instructions have been given to(tu ww d6edarnsme)
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. ( Ynwwl Pine View Crematorium I 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 rernains wilt be destroyed by the cremation process and cannot be retrieved
after cremation.
C Cx UWe hereby authorize(crsrr�t ,-.) Pine View Crematorium to cremate the
rem ns of the deceased.
FINAL DISPOSITION
The person authorized to receive the cremated remains of the deceased from the crematory is:
Name: C.14RiSTi RA GRA14AM
Address: tjop(o I6"Sr Lie. t 14y 11161 Phone:�(o4(0� (o�3 ',Z?Gos'
The cremated remains of deceased will be disposed of as follows:
fRF.."C' e l TO r-AMIL.1(
if for any reason the person named above does not take possession of the cremated remains,
(m m fty name) Pine View Crematorium is authorized to give possession of the remains to
(fi#wW w w mme) HWO M 41E"L S EftCES rR C, by delivery in person or by registered mail.
CLASISE GRANAM
ws-lsm-" (Rev.01110) Nam ofDomsed Page 2 of 3
May 06 20,03:33p p 3
(k tlBt the following)
INVO understand that if the remains are not claimed within 120 days of cremation,
(c►erratoy►wm) Pine View Crematorium may dispose of ilia remains in an irretrievable manner,
such as by scattering.
CREMATION CONTAtNERNRN
(a ' t ONE of the following)
An um 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 um is too small to hold the entire cremated remains, an additional rigid container may be
used for delivery.
-OR-
W An um has not yet been purchased. INVe understand that if no um is purchased or otherwise provided
(cre mwynwmj) Pine View Crematorium will place the cremated remains in a rigid temporary
container for delivery.
This Authorization Form was provided by mmetw cod nsme)_ K E.[ (t-ietg K oo D
was executed at tanww fame nmr,e) 06 D FV t4 L&&%,.. SO ices r
(funeral adti sssl_ (o b 1 f t TKl i V ME- R KuYN M Y 1 I AO T 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 islam 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 authorizes)the foregoing.
Signed this l sr day of MAY yp 0
0-141U M A UARA K L)—�
Typed or PdnW Ns►ne
Soo(v to*" ST �.�c � Ny 1110 t
Address
Typed or PrWd Name
Address
Typed or Prnked Hams Signature
Address
WITNESS:
KENNE3JA ROOD
Funeral Dkector Typed or Primed Name Funs�da0ag Sfg uture
l l(o51
Reyfdretbn NunWW
UARt S E GAALAAM
DOS-189844 (Rev.01110) Name of Deceased Page 3 of 3