Brown. Udel Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
it It,
FUNERAL HOME: ��t� RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: _� T zo /' k C o
NAME O//F��FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
NAME: LCki- Z ,ow-r-) CASE # \5 6
TYPE OF CONTAINER: evAk
PLACE OF DEATH: Jk) 4 d leak
ESTIMATED WEIGHT OF REMAINS & CONTAINER
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION: S - ?—2y'Z 0
TIME STARTED: Z�►'1 TIME COMPLETED: �3
PLACED IN RETORT: �15 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'Q5 20,03:33p P•1
NYS Department of State
Authorization for Cremation and Disposition Divisio of Cemeteries
One Commeroe Praia,99 WashkVon Awwe
Albeny,NY 12231
(518)474-6226
www.dos.shft.ny.us
This Authorization Form must be completed and signed prior to delivery of remains for cremation.
Date: .1-1I a010 Number: -A`&
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: U bEL NOW k Marital Status: W i DOLZ D
Last known Address: 113(o ST. MAM AV P- (3KLIN . hj Y 11 A 3
Place of Death: Q-9,ou (Al 4ekG44 r tAUtl5t NG c.'rQ. agoo KL`(N N Y
Sex: OM F Age:� DOB: I93$_ Date of Deafty-3 1A6 I 20,zo Estimated Weight: I(Q ibs
Description of casket/container in which remains will be delivered:
Alternative Container QAQbS0r4Rt
PERSON IN CQtJ L OF DISPOSITION
(Person(s)m control of disposition,iniSal 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
1Mle have no knowledge that the deceased executed a written instrument pursuant to Public Health Law
ction 4201 or a will containing directions for the disposition of his or her remains and (continued nextpage)
O b Ei, B R U-)[%4
DOS-10V4 (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:
(Insect fnxn the list below)
Number: .3 Description: �CiNI
1.A person designated in writing pursuant to Public Health Law section 4201(3);
Z.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;
*A lawfully appointed guardian;
7.Any person(s) eighteen years of age or older entitled to share in the estate and who islare 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 Sur ogaWs 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)
r [Me hereby affirm that the body of the deceased does not contain a battery, battery pack, power cell,
►oac Live 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.
VA INVe hereby affirm that instructions have been given to frarrors►dFredorname) kEi4N E.'1;'14 1400P
rdgarding 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. (vemefory name) Pine View Crematorium 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.
W6I/We
reb
hey authorize(aematwynama) Pine View Crematorium to cremate the
of the deceased.
FINAL DISPOSITION
The person authorized to receive the cremated remains of the deceased from the crematory is:
Name: u S V F SP,6l R
Address: 1 7%3(o SY MAI KS AVi, R KL
jgjt4y I I A t 3 Phone:O vl ,3(o51
The cremated remains of deceased will be disposed of as follows.
.RETuRIA TO SAMILY
If for any reason the person named above does not take possession of the cremated remains,
(mmatwy norm) Pine View Crematorium is authorized to give possession of the remains to
(funerWhwwname) ROO D PVt4 O-AL SEIQ.VICES TWC . by delivery in person or by registered mail.
VOEL. BROWN
DOS-1N W4 (Rev.01110) Abm of Doomed Page 2 of 3
'May 0,5 20,03:33p p.3
(In'i the following)
V I/We understand that if the remains are not claimed within 120 days of cremation,
( matorynorm) Pine View Crematorium may dispose of the remains in an irretrievable manner,
such as by scattering.
CREMATION CONTAINERIU-FtN
(Initial ONE of the following)
An urn to be used as a container for the cremated remains has been purchased from
and is described as follows:
INI/e understand that if the urn is too small to hold the entire cremated remains, an additional rigid container may be
used for delivery.
-O
An urn has not yet been purchased. I/We understand that if no urn is purchased or otherwise provided
(crematory name) Pine View Crematorium will place the cremated remains in a rigid temporary
container for delivery.
This Authorization Form was provided by(funeral director norm) I<EA4t4eaR
was executed at(funeral home name) 14 oo b F1JI teAL S E1t.V (Ev-S =tAr-F
(funeral home address)11D6t POM N /SUE B KLYN lgt.Y l(dog and is signed by the funeral director
as witness to its execution.
ItWe 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 accuracy and completeness of the information contained in this
Authorization Form and authorize(s)the foregoing.
NI/�
Signed this 2 day of Y Z 2020
YUSUF: ,>Rowc*j
Typed or Printed Name Signatu
1X3Co S - M KI AVF- BKUYH f MY l(zt
Address
Typed or Printed Name Signature
Address
Typed or Printed Name Signature
Address
WITNESS: n
KWctCr-VA 600? \\
Funeral Director Typed or Printed Now Funeral Director Signature
11651
Registration Number
U DEL- SROWN
DOS-189844 (Rev.01110) Name of Deceased Page 3 of 3