Kandes, Allegra Marie Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: nD KLLIAEL RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: �1-)1 zb
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
�pp Xu,�it,
NAME: Alu G!•!� K��Lp CASE # s-5g
TYPE OF CONTAINER: } 10cf., 6 4144 Co, I "Wd CaE'fv
PLACE OF DEATH: Tlx Pnt.S dur's�c -�bmG.
ESTIMATED WEIGHT OF REMAINS & CONTAINER S-0
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION: {� s
TIME STARTED: � 15 f h TIME COMPLETED:
PLACED IN RETORT: ' �p� MOVED:
RETORT # IN WHICH REMAINS WERE CREMATED: __ i'• P
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.
N—VoA
Department of State
NEW YORK DIVISION OF CEMETERIES
ATE OF Division of
OPPORTUNITY
Cemeteries
NY Q2.31 o0c
Authorization for Cremation and Disposition
This Authorization Form must be completed and signed prior to delivery of remains for cremation.
May
Gate N.a�her
Crem3tc,Y Name Puie View C,e,i a:o,y
Adc!ess 21 QuaKo,Roaa Queensbwj NY �'i!-745 4.176
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS
Crem3non is carried out by placing t-e eriar,%nf IhL JvEedsej vij the centainar h�ioing the repiwns,nto a ci-en-auon chamber where
they are s,bjecTPd!r;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 cromalior, Pie crematory will take reatonab!e efUts to remvt dil e,i-atils and it"e,material'rom the c'emallon
chamber but some -,ir-4 dUST and iesiot,e-11 1--ev ce left oe-nd I he-len,alo,y w I soua,ate incile-tai"ind foreign matenal'(on,
the rema.-s and:he incidental anrj ioreign ma:eiial wit,be Jisposea of as•eq,-red C,,law The•-.iemated remanii; v I he i)eChari,Ca y
uolveraea vto small oleces and placed inic a designated cci-tairvi nr wr Cremated remains generally are pulverized until no
single fragment is recognizable as skeletal tissue
OPENING OF THE CONTAINER
The crematory may only open the uintawe,holding:he un-creiviwed 1,unrs^'Prnains it lira Iwi c,-c,,.mstances such as to confirm t^e
dentitv n'the deceased or-.o erSUF0 that no mateiril is on,-Jospol which rnignt in;uie e-roloyees ci damage the cxemaluyy 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
co^ta!ne(or;he transferor removal o'remains vviii be conout:!ed beforea Yj tress and wil be oone in privacy , r: ognity and respect
N.h 9 , pe
IDENTIFICATION OF DECEASE
Name of Deceased Allegra Nia,:e Karides manta)Status C--b
Las-,Known Add,,ss 1'0 Warren St:pet Glens Fa s NY 128C-
place of 0eW, I he Pme3 Nursing HomeAc:e,,-1'3)-DOB 03 14'93,; (:,aIe dI Death May.1 7020 Estimated Weight 1
50
Descfotior of caske:lconlainer ri vh ch remains wil! ,e oelivvcd
Fioronc;e Caskc?G.- 101,11MUM C;rpmaiicn C3sket iplywccc conugale,i cwuboarcii
PERSON IN CONTROL OF DISPOSITION
fFi covl,oi o,d,Sj;o!.Woii india.-Oiyt fl tP:e
I a;1i,We are We designated agent of:he deceased dcs.ora:eu :1 a wIl of vi nuri jris:i joier,t executed purs-alt to Public
Health Law Section 420'
ciq
%— - IVVc have no Kn,-.W1EJ9e viat tie deceasc-c executed a written instr fnc:,l p.,5.ant to Pub,ic Health Law Section 4201 or a
wm ContalollIg a_tjors;for the disDasition of his of her remains ano 1,we are the person(S!having oriority under Public Health Law
Section 4201 and have the right to autricrize cremation o'the remains of ine leesased MylOur relationship to the deceased is as
follows
Allegia Kafces
DOS 1898-fiRev 0&15t Page 1 of 3
Authorization for Cremation and Disposition
0113e1i imo,the slit hrik )
Number Descrpilor Survrwng Child eighteen years of ape or o+der
1. A person desrgnateo in writing cursuant to Puohr Health I at.Sect on:201.3!
2. The surviving spouse.
2a. the surviving domestic partner
3. Any survivirg child eighteen years of age of older
4. A surviv!ng parent
5. A su vivmg sibling eighteen yeas or age o o ue,
6. A lawfilly appointed guardian
7. Any personas;eighteen years of age ar older ertitled to sna'e••,1he estate ano who is%are Closest n,feladOnahrp t0 the deceased
8. A duly appointed f,duciary of the estate
8. A c'•ose friend of relative wnc has execulea a maven stetemerd p..,s_a^I:c Puefic Health Law Seeder 4e0'(7)
10. A Cl fiscal officer of a county or a public administrator arpe!hteo r.irs,.am!o:he Surrogate s Court Procedure Act
t0a. A r v other person whc is acing ur'1)ehalf of the ceceasec a,7 who has executed a written s late rile.ri pursuant to Public Health
Law Section 4201,7)
!: r 1 1 ALL hREE,,It MP In!fomm,
�} I'iAVe herecy affirm that!tie 000y of the deceasec does not contain a batle'y battery pack power Cell radioactive implant
gr radioactive device a^d thal any Such mntonais were re—over:p•o-to the cxuculicn o4,hr Authorization Form Failure to remove
these items prior to cremation may result in harm to the crematory and crematory personnel.
t- IA „��,LI'we of,ro,:oat ins•,udro^s^ave been gidcn to Step-anw(=duian
regards^d the removal of tiny personal crnpely or other ining of value which Iny P—sor s gnnrg Uelcw or ary fa•nily memoer of the
Pine View Crematory
deceased w•ches t�press vo
is not responsio!e for-,he removal of pill lens(min the container or front the rung ns 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
M.,IIWe hereby authorize Pine View Crematory
to cremate the remains of the deceased.
FINAL t)ISPOSITION
The persor authorized to receive the cremalec remains cf the Jecedsed from I^e crematoryy�s
Nar•e M B Kil•ner Funeral Home
Address 52 Broaaway fort Edward NV'2828 Phone 518-747-9266
The cremated remains of deceased will be u-spousd of as foCows
Burial al Gen.Fulls Ceti elegy
If for a„y reason the oerson r a'ned 9bcve ales^.ot!aKe posse'sic,of the,c rateo'enla-"s
P,ne View C,erratory is authorized to g•ve oossession of
the remains to M 8 Kilmer Funeral Home _ oy ale,.ery
in persor o•by registe-ed mail
Alleara Kandes
DOS 1 R98-'(Rev 08i.5, Page 2 of 3
Authorization for Cremation and Disposition
flnlfral;he rnlldwm�i
I/We understa^C that it tho remains arc ro;CIA1,11ed wi,h.n 120 lays of,i i)aticn
Pine View Crematory
may grspose or the•emains in
an ifletrilevaole marrne' sucn as oy scattering
CREMATION CONTAINER/VRN
i lndi8/ONF o/fhe'odnv.rrq;
A^err.to bf!used as a col•la•re'Ior the pie-neiE•u:e,-rums hcis keen purchased from _
a-a is described as'ouows
1,We understand tha:it the urn is too sma"to hold the entire c,omated remains an and l onal i:gid container may De used for delivery
-OR.
q
!Kk ,_An urn.s not yet purchased IIWP understand that i no um is p.,rcnaseC or o!ho,w.se orowded
Pine View cremato•;
--- -- �..•— -- --- __�._ _.._ will p,ece the cremated remains in
a rigid temporary cow.ame-for oelrve,
This Authorization Form was previde❑by Stephanie:;dray
was executed at
M B Kilmer Funeial Nome
82 Broadway Fort Edward NY 12828
and s signed gy the funeral direcicr as witness:o i!s executen
Wye have received a comple:eo copy of this Authorization Form
The person(s)identified below islare 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(ill)the foregoing.
Signed this 5th day of May 20 20
Margaret Leve: r�-
7036 Benhall Circle Gen Ater VA 23059
WITNESS:
Stephanie Gilman
141153
A.egin KAndCS
DOS-1898-f.Rev 08i'S! Page 3 of J