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Abrams, Baby Pine View Cemetery & Crematorium Quaker Road Queensbury, NY 12804 (518) 745-4477 or (518) 745-4476 FUNERAL HOME: J�X&,Z4 � RETURN TIME: DATE & TIME REMAINS ARRIVED AT CREMATORY: J LO NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS: e NAME: / CASE it b / TYPE OF CONTAINER: 4 PLACE OF DEATH: ; ! - ESTIMATED WEIGHT OF REMAINS & CONTAINER Ld PLACED IN HOLD: PLACED IN REFRIGERATION: DATE OF CREMATION: �' "— TIME STARTED: ho a/h TIME COMPLETED: 11104 e-n PLACED IN RETORT: �O2- MOVED: ✓✓ RETORT # IN WHICH REMAINS WERE CREMATED: �C7W" 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. Z. l� AUfzatipn for Cngmation and Disposition Or*ctur Plus. Maim of c&ft"O" 9D Mtn My IMI M18)4744228 - Form cwww.tlosttst� 'apdams nd S* d Pdor todbivyY of rmaiaaorrenstasng.ems: . Crc Number: C�eabory Nam: — ��' mato AddrOft. 21 1 �uC [ISi�I lty NY Y 12804 Cl ►' 1 JS AM IN =1/ER$1 Phone:_�18)745 4476 Crornai is d out eil AND FIIN�►! PROCESS. �� Y V the remains Of ft We subs to deceased and the container holding the remains into a g . The heat and fIsmq the crematory roft a me41,which are all that will be left after cremation 11 incinerate and the crematlon 'but some m ima�dust anke d illtill( ove all of the remains and other materW from from the remains arRi Y be left behind. The crematory win separate ►' d remains will incld�tal and foreign material will be disposed of as or UM' CY Pulverized into small Pieces and placed into a "sawQsneraliy are Pulverized until no single fragment Is .. 'hieopen �xy IN) the the Wry h'�ng it*un-Mmated human remains in limited circumstances, such Aft" renod Of ds are d en*"that no material Is enclosed which might injure employees or lr �,P0 er, sterna varod In a container which Is not suitable for cremation . 01! toy►w#1 rr•qulrg that the remains be moved into a suitable t 7 p a and*ill be done in oP°r*lg Of a container or the transfer or removal of remains will be privacy,with dignity and respect. � �ieoniPd: Bey Aims Marital Status: Never Married • =5?-25 Ctvde Streei,Forts#Hills,NY 11375 � � • ��tJbiv+e�i �I' 30U Community Drive M —_—`�x anhasset,NY 1103U 4----- ' 1 L s Of Death: 4/14/2020 Estimated Weight: irl whi+ t'emattts w be+delivar+ed: limp mated in a wi8 or*"w weir~exec msd ¢. A1r1 11 11atrU111 :pUrt4t!p4d ' . (W tW M(Rai is t 11i►+r1�rQ r xl �• ��� ��`�� i1�#mod t° __j.91'!t . y ; I arrd vre are the psrson(s)having priority under Public Health Law section 4201 and have the right to authorize - COMMIlOn Of the remains of the deceased. MytOur relationship to the deceased Is as follows: ~ftm fist b@bW) Number: option: ©att..7 1.A designated In Willing pursuant to Public Health Law section 4201(3); L The oxWving spouse The surviving domestic partner: 3.Any surviving child eighteen years of age or older; 4.A surviving parent; &A surviving Ong eighteen years of age or older; &A WAft appointed guardian; 7.:Any person(s) eighteen years of age or older entitled to share in the estate and who is/are closest in neIAIWIshIp to the deceased; L A duty appointed fiduclary of the estate; L A dose MeW 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 s , Y `AOILAM allm parson who is acting on behalf of the deceased and who has executed a written statement WWAKt to Public Health Law§4201(7) THREE ofttrs kWow*Vj hereby eflrtrtn that the body of the deceased does not contain a battery, battery pack, power cell, or rad"aective device and that any such materials were removed prior to the execution of this it Q1'ili3ll)kut FWM-Fagan to remove these items prior to cremation may result in harm to the crematory and hereby affirm that instructions,have been given to mxwni&ecw nme) Steven Duca # t the removal of any persons!property or other thing of value which any person signing below or any family ! t�f ttM deceasedwishies to preserve.t mmoynamy Pine View Crematory is not ft foMoVal of personal items from the contatner or from the remains of the deceased. Personal items it eiwl11ll1 or!at r 00 re nalm*0111 be destroyed by the cremation process and cannot be retrieved belfty Oullvad a fCrsmeftyn4m) PiDe View Crematory to crenate the �t e:�1►�MiMel. 3 - Ilii irlir ale c +elmaad resrtadne "deceased from the crematory is: 4 MM Fat NY 11375 Phone-. (719)268-7711 t titiield be dispowd of go of the cremated ram, { of ere M**to to give Pl'�Itl or M1 � s AMm of Dooesaad pa3p 2 Of; , w WOV1 understand that if the remains are not claimed within 120 days of cremation, . i 'irle View C Atr►D may dispose of the remains in an irretrievable manner, such as by scattering. RN ONE of tape to in91 An um to be used as a Container for the cremated remains has been purchased from Fox Funeral Home Inc. and is described as follows: end that if the um is too small to hold the entire cremated remains, an additional rigid container may be used for delivery. has not yet been purchased. UM understand that if no um is purchased or otherwise provided Pine View Crematory will place the cremated remains in a rigid temporary CWWW for delivery. '1'�e A00wrizadon Form was provided by(ru► W name) Steven Duda IM&VOPA*d at omw ho oe nave) Fox Funeral Home,Inc. tt+an«, ) 98-07 Ascan Avenue,Forest Hills,NY 11375 and is signed by the funeral director Witness to its execution. 1`11Mte MOSived a core ple W copy of this Authorization Form. t1 tt� )tderFr ed be km blow the parson(s)in control of disposition,who by signing this 1r�0A Pwra,ageogs)to the aeccueacy and compk4eness of the infonnation contained in this h +pkn Form wd aU#harisa(s)the foregoing. x Mil! 2n+d day of May 2U 5 7N Forest NY 11375 f 0 , � 4 7` Aa 3 , r