Ramsey, James ,S r( l
Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: _4®a,I 1' /
RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY:
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
NAME: J CASE #
TYPE OF CONTAINER:
PLACE OF DEATH: I5 ZO A-V,.O- -,:�q 0--1,4 l0 gf'Y3
ESTIMATED WEIGHT OF REMAINS & CONTAINER lea- 3qq JI -
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION: S q 170
TIME STARTED: ._ 7`90 TIME COMPLETED:
PLACED IN RETORT: $ MOVED: '�(� /8%Wool
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.
toy 05 20,W-.33p P.1 S 4 ((
WS lumt Of Slab
Authorization for Cremation and Disposition o C
One coff""M Plaza,99 V611WIMW Avenue
Ate►,W iml
(518)474-Mb
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77ifa Atctt W&Won Foam moat be amwisted and signed pdar to AWvwy of rm ems fbr morn.w
Date: 5191aw,0 Number: S,71
crematory Name:Pine Yew Crematorium
Address. 21 Quaker Rd Queenabury,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 armed to intense heat and flame-The heat and flame will incinerate and
consume everything eucept bone and metal,which are all that will be left after cremation.
Following cremation,the crematory will take reasonable of b is 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 mcklental and foreign nut na l 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.Crenated remains generally are pulveriited until no single fragment Is
rec ognbtable 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 migtlt injure employees or
damage crematory property.if human remains am 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.
IDENTiEWATION OF DECEASED
Name of Deceased: SAU L S PAM S E-/ Marital Stsbus: jJ11/ORC:i`D
Lest Known Address: I �1y STO P-'1 ME— A P i :9014 Uot4x }t,!1f �O y 73
Place of Death: t 5X0 ST-O y V t r Q tW k t-1 l 0 4 73
sex: �M I]F age: lob. DOS: 2110, 1959 Data Death: 41 i 3))oao Estimated Weight A
167 lba
Description of calsketkontainer in which remains will be delivered:
alternative Corrtainer CAW P_)pA-iLD + i,=c>
PERSON IN CONTROL OF DISPOSITION
(Perac $)in cordial of disposA n j4d ONE of the following)
i arnl We are the designated agent of the deceased designated in a will or written instrument wnc uted
pursuant to Public Health Law section 4201.
-OR
CL l Vie calve no knowledge that the deceased executed a written instrument pursuant to Public Health Law
section 4201 or a will containing directions far the disposition of his or her remains and (continued nWpoW
-YAM -9, PVS SE'i
Dos-law-" (Rev.onto) Aftm a/Doegand Page 1 of 3
Rty 05 26,03:33p 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:
(/nett from the list below)
Number:_ Description: S ISTEA
1.A person designated in writing pursuant to Public Health Law section 4201(3);
2. The surviving spouse;
20.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;
&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 SurrogaWs Court
Procedure Ad;
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).
(t[iltifll ALL THREE of the Wowing)
C L me hereby affirm that the body of the deceased does not contain a battery, battery pack, power cell,
radioactive impiant,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 L- IM/e hereby affirm that instructions have been given to mme,a &@ctoraame) KENJr--r -, 1-1t OD
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. l ,y,w.l 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.
C r` IMe hereby authorize(awwt y Hamel Pine View Crematorium to cremate the
rema n of the deceased.
FINAL DISPOSITION
The person authorized to receive the cremated remains of the deceased from the crematory is:
Name: C.A&cor., (Zm-ts Y /
Address: l()l —1,),5 W I`t-1 tf4SViL r-T `APr"t At S\1 N1. IVY 100 39 Phone(gl� St 3 -L4e9 S
The cremated remains of deceased will be disposed of as follows:
� TL)Kt4 To F-kKILl
If for any reason the person named above does not take possession of the cremated remains,
(,as nwwy m m) Pine View Crematorium is authorized to give possession of the remains to
( nwm) 14WD R)ACOL SWICI�S ZrNC by delivery in person or by registered mail.
JAM V.0_ VA 1\4SEY
DW-18W44 (Rev.01110) Naafis of Doannd Page 2 of 3
h+W 05 2Q'03:33p p.3
(1aM the following)
�-rL I/We understand that if the remains are not claimed within 120 days of cremation,
(mffw rynarm) Pine View Crematorium may dispose of the remains in an irretrievable manner,
such as by scattering.
CREMATION CONTAINERIMRN
ftti l 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:
I/We understand that if the urn is too small to hold the entire cremated remains, an additional rigid container may be
used for delivery_
-OR-
CR- An um has not yet been purchased. IIIIVe understand that if no urn is purchased or otherwise provided
(am„ b y nam) Pine View Crematorium will place the cremated remains in a rigid temporary
container for delivery.
This Authorization Form was provided by mMWWdWCWn&-ft) KE.No�TR 14Wb
was executed at mnerw t ome rrorrre) ti00 ES�tAc-JAL
MmeW house address)_j uOl eLTK 1 t,4 A V E- kLY N3 NY t l A0$ and is signed by the funeral director
as witness to its execution.
IMie have received a completed copy of this Authorization Form.
The person(s)identified below islare the person(*)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.
�tM
Signed this day of MAY 20Typed or
A ^Printed Name ty l ��S cf-'r 6APT' tSI� 7 1003`I �—
Typed or PiVnW Name s wure
Address
Typed or Printed Name S
Address
WITNESS:
K Q,U- ✓yI.-t t c1DD
Funeral Director Typed or Prtnted Name Funeral Director Sigrretare
111�5�
Reylsdawn Number
DMI B9844 (Rev.01/10) Name of Deceased Page 3 of 3