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Negron, Victor Pine View Cemetery & Crematorium Quaker Road Queensbury, NY 12804 (518) 745-4477 or (518) 745-4476 FUNERAL HOME: _ JC_kt',_„ 1e i Ap __ RETURN TIME: DATE & TIME REMAINS ARRIVED AT CREMATORY: - NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS: mj�L� ? 9__4�,� NAME: _—. (TOr / CASE # TYPE OF CONTAINER: _ JitJC9c?C�e 9 14/45„i A(,2 O PLACE OF DEATH: 5rOY1 ESTIMATED WEIGHT OF REMAINS & CONTAINER_______ PLACED IN HOLD: PLACED IN REFRIGERATION: DATE OF CREMATION: _ SIZ IZO TIME STARTED: .__ 1 � -----.--TIME COMPLETED: 9_ �bA_All PLACED IN RETORT: 3 MOVED: �If �� �T1 RETORT # IN WHICH REMAINS WERE CREMATED: _ UAL �klll 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. New York State Department of State NEWYORK pivision of DIVISION OF CEMETERIES STATE OF One Commerce Plaza OPPORTUNITY- Cemeteries 99 Washington Avenue Albany,NY 12231-0001 Telephone.(518)471-6226 Nynv.dos.ny.gov Authorization for Cremation and Disposition This Authorization Form must be completed and signed prior to delivery of remains for cremation. Date:4/27/2020 Number: Crematory Name: �9 Address: x �� -`1�` �`Ti � Phone: �/0?q,,�yy 7 2 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 THE 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 the crematory 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 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:Victor Negron Marital Status: Single Last Known Address: 3845 Carpenter Avenue Bronx, New York 10467 Place of Death: Bronx Park Nursing Home Sex: © M ❑F Age:62 DOB-4/15/1958 Date of Death:4/26/2020 Estimated Weight: \&0_ Description of casket/container in which remains will be delivered. wooden container PERSON IN CONTROL OF DISPOSITION (Person(s)in control of disposition,initial ONE of the following) f 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- IM/e 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 I/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: Victor Victor Negron Schuyler Hill Funeral Home DOS-1898-f(Rev.08115) TR050120_FH06/C09/045 Authori-4.1tioll for Crtiniatiorl and Disposition V !1',j Z")h"0011 vv'al-z"t 01'oldv`' A 0 S!", 1P t'hteon l Oill"Of Of 014101" of ago or older entitled to gjj;jl o in the 10 111ki who iy�art?closest in relationship I the d Sed S. 0 ece It N the io aive%%ho has et\ 'utod a wrliten statement pursuant to Public Health Law Section 4201(7); 0 a'Nikilli\ or it public adillinle'trator appointed pursuant to the Surrcigate's Court Procedure Act, 'utwg on bolialf of the deceased and\#Aio has executed a written statement pursuant to Public Health I 11 e hvretn ;Ifimi that the body of the deceased does not contain a battery,battery pack,power cell,radioactive implant, 1p'W\;ce.and that anv such matenals were removed prior to Ilia execution of this Authorization Form. Failure to remove These items prior to cremation may result in harm to the crematory and crematory personnel. IA71 XT-irn that insnctions have been given to Jeannine Carbone v-,e of any personal property or other thing Of Value which any person signing below or any family member of the n w o p stncs treserve. �j\lt—W C1, M oNn Manx-) for the 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. I We hereby authorize \oe-w C tMCAC;ey I',cremate the remains of the deceased. FINAL DISPOSITION po au—,,r:ed to receive the cremated remains of the deceased from the crematory is: Na7'e —1-chuv!er Hill Funeral Home 3535 East Tremont Avenue Bronx, New York, 10465 Phone: 718-792-0270 71-o renia ins of deceased 011 be disposed of as follows: return to family from Schuyler Hill it',,r ari%, 7eason Lieron named above does not take possession of the cremated remains, is authorized to give possession of :fle(e.na"Is to, ,5chu filer-Hill-Funeral Home 'n dell\erN cie.son or b\,regiMered mail. VictorN Victor Negron S R Schuyler Hill Funeral Home TR050120_FH06/C09/045 Authorization for Cremation and Disposition initial the following) I/We understand that if the remains are not claimed within 120 days of cremation, (� -- ma%,i rI,osh(if the tc•,':". (Name of crematory)an irretrievable manner,such as by scattering. CREMATION CONTAINERIURN (lritia!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: WVe understand that if the urn is too small to hold the entire cremated remains,an additional rigid container may be used tot de'i/Sri- -OR- d An um is not yet pur sed. I/We understand that if n7 is purchased or otherwise provided r e { rill place the cremated remains in (Name ofCremetoty) a rigid temporary container for delivery. This Authorization Form was provided by Jeannine Carbone °uas executed a: (Funeral Director flame) Schuyler Hill Funeral Home (Funeral Home Name) 3535 East Tremont Avenue Bronx New York 10465 (Funeral Home Address) and is signed by the funeral director as witness to its execution. I Mde have received a completed 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 accurac ompleteness the information contained in Ns Authorization Form and authorize(s)the foregoing. Signed this day of ,20 AnthonyNe ron Taped"Pnnted Name S ratu'o 129 Sorrli Red Ct Warrenville South Carolina 29851 Aovess Typed orrPrtrred Name Signa7ure Address Typed ar Pnnted Name sgnstura Address WITNESS: Jeannine Carbone (Fur*ral Dvecror Typed orPrin(ed Name) (F�real-Drec'er 5 �a Hai 10534 (R@VSVd!,on Nurnher) Victor Victor Negron Schuyler Hill Funeral Home TR050120_FH06/C09/045 DOS-1898-f(Rev.08/15)