LoMedico I
Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: 4- , - RETURN TIME: ��
DATE & TIME REMAINS ARRIVED AT CREMATORY: lq 70
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
__mrhe
NAME: _aaIWI 1 y'.2 ( Clj CASE # _
TYPE OF CONTAINER:
PLACE OF DEATH: V-Ct04.,� --
ESTIMATED WEIGHT OF REMAINS & CONTAINER _4� Z �Z �✓ S
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION:
TIME STARTED: . L)5 ____TIME COMPLETED: 1 '30 P1�
PLACED IN RETORT: _ _ J - IwAtl MOVED: ___ (Z 16em
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.
New York State
Department of State
NEWYORK Division C?f DIVISION OF CEMETERIES
STATE OF one Commerce P:aza
OPPORTUNITY_ 99 IAA)shington Avenue
Cemeteries Albany.NY 12231-0001
etephone:5118;474.6226
wa..,.do�.ny.co•:
Authorization for Cremation and Disposition
This Authorization Form must be completed and signed prior to delivery of remains for cremation.
Date:4/28/2020 Number:
Crematory Nar„F:
;address:--_-� ' �� ., ��J r _1t t I �_ �� _Phone:
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation is carried out by placing the remains of:he deceased and:he container holding the remains into a cremation chamber where.
they are subjected'_o intense heat and flame. The heat and flame wiil incinerate and consume everything except bone and metal;
which are all that will be left after cremation.
Fc1lowing cremation.the crematory will take reasonable efforts to remove ail of the retrains 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 ircidentai 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 ioldirg 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.ransfer 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: John LoMeCico Marital Status:Married
Last Known Address: 3179 Rawlins Avenue New Ycrk, 'New York 10465 _
Place of Deatn: Providence ReSt
Sex: C N1 ❑ F ,age:78 Dos: 8/25/1941 Date of Death:4/26/2020 Estimates weight:��0
Description of casket'container in which remains will be delivered.
Matthews International Casket Company Union Ciptht Covered _
PERSON IN CONTROL OF DISPOSiTION
1Person{s)in control of disposition.initiai ONE of the following)
I am'"We are the designated agent of the deceased designated Jr. a will or written instrument executed pursuant to Public
Health Law Section 4201.
-OR-
[.,'We have no knowledge that the deceased executed a written instrument pursuant to Public Health Law Section 4201 or a
if containing directions for the disposition of his or her remains anc Uwe are the person(s)having priority under Public Health Law
` ection 4201 and nave the right to authorize cremation of the remains of the deceased. My/Our relationship to the deceased is as
ollows:
John John LoMedico
Schuyler Hill Funeral Home
TR050120 FH06/C09/049
GCS-1898-f(Rev.08!15)
Authorization for Cremation and Disposition
(insert from the list below)
Numoer: 2 Description:Wife _
1. A person designated in writing pursuani to Public Health Law Section 4201(3);
2. The surviving spouse:
2a. Tne surviving domestic panne-
3. Any surviving child eighteen years of age or older:
4. A surviving parent:
5. A surviving sibling eighteen years o`age or older:
S. A lawfully appointed guardian:
7. Any person(s)eighteen years of age or older entitled to share in the estate and who isiare closest in relationship to the deceased:
8. A duly appointed fiduciary of the estate:
9. A close friend or relative who has executed a written statement pursuant to Public Health Law Section 4201(7):
10. A chief fiscai officer of a county or a public administrator appointed pursuant to the Surrogate's 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 Section 4201(7).
(initial l LL THREE of the following)
L me hereby affirm that the body of the deceased does not contain a battery. battery pack. power cell, radioactive 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.
t , Me affirm that instructions have been given to Toni .inn Cicalo
,i nera'D;•.,ct:Nov-•
regarding the removal of any pe sonal property or other thing of value which any person signing below or any family member of the
deceased wishes tc preserve. --
.-._.r,:�scrr
is not responsible fcr the removal of personal rerrs from the container or from the remains of the deceaseo. P"ersonal iterrs left in the
container or with t-ne remains will be destroyed by the cremation process and cannot be retrieved after cremation.
i Me he, authorize
to cremate the remains of the deceased.
FINAL DISPOSITION
The person authorized to receive the cremated remains of the deceasec from the crematory is:
Name: Schuyler twill Funerai Horne _
Address: 3535 East Tremont Avenue. Bronx, New York, 0465 Phone: 718-792-6270
The cremated remains of deceased will be disposed of as follows:
Give to a funeral home reo. to be returned to the fam. ily
`f for any reason,the person named r ove does not take po�1ssion cf the cremated remains.
t ; ((•�;(,+ UV fT\.dD \ 1_ is authorized to give possession of
,he remains to Schuyler Hili 1=uneral Home by delivery
fr,mo!ai Home
:n person or by regis:ered mail. John LoMedico
Johr: Schuyler Hill Funeral Home
TR050120_FH06/C09/049
DOS-1898-f(Rev_06/15)
Authorization for Cremation and Disposition
(initial th following)
f/We understand that if the remains are not claimed within. i o
� � �0 days of cremation,
may dispose of the remains in
an irretrievable manner. such as by scattering.
CREMATION CONTAINER/URN
(Initial ONE of the following)
An urn to be used as a container for t,e cremated remains has been purchased from
and is described as follows:
dwe understand that if the um is too small to void the e:ttire cremated remains.an additional rigid container may be used for delivery.
-OR-
Cti An urn s not yet purch d. IN'Je understand that i�o um s purchased or otherwise provided
t M � will place the cremated remains in
rJa c a:C•el!"Wor::
a rigid temporary container for delivery.
This Authorization Form was provided by Toni;-Ann Cicaic was executed at
Schuyler _.Hili Funeral Horne
-F.r„rr.:,NGera
_3535 East T-emont Avenue, Bronx; New York 10455
and is signed by the funeral director as witness to its execution_
I/We have received a completed copy of this Authorization Form.
The person(s)ider:tified below is/are 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.
Signed this _ day of 1/r t ,20 t:: '
Julia Lo /edico t� L
T-'r c�F•ar[ed Aia!re
a aab a
3179 Rawlins Avenue, New York, New York 10 5
.•iC�!FSa _ _.
WITNESS: '
i orii Ann C-icaio
c. ,r n; a'J.:^_.� Sid:. .•re- _ -
1V651
John LoMedico
Joh Schuyler Hill Funeral Home
T11050120_FH06/09/049
DOS-1898-f(Rev.0E:15)