Bynum, Elvin Pine View Cemetery & Crematorium 72-
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: �' _ __ RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: 'q Zo
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
NAME: _6 CYO/1 2 CASE # S
TYPE OF CONTAINER: "010 G�iltice �G -y�•, lz_�
PLACE OF DEATH: yvk /�s r - ld'lOd
ESTIMATED WEIGHT OF REMAINS & CONTAINER____ _`qlo " J_ ZSO ,7
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION:
TIME STARTED: _ ' ' -_.TIME COMPLETED: � 7�
PLACED IN RETORT: I -►D 1 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.
MUyr35 20,03:33p P.1
NYS DoWn ent of State
Authorization for Cremation and Disposition DWWW of Cep
One Commam Plaza.99 wsshkVon Avenue
Albany,NY 12231
(518)474$226
wvm.dos.stste.ny.us
This Authorizadon Form must be completed and signed prior to delivery of remains for cremation.
Date 4 b Number: L /7 2—
Crematory Name: Piro 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 n
Name of Deceased: F—LV I N DY to m Marital Status: MA UIQ
Last Known Address: 15R 6 kOO K L1f t-( A S— B Kc..`(R i, f 4 y I l 1106
6
Place
,,__of//Death: UNIVeLSITY RC)S@tIC4k 0 IRAGp L c4 ,( 99WKLYN f tti(lf�
Sex: -`L9M ❑F Age: DOB: Date of Death:4-� OAO Estimated V1leight: 190 Ibs
Description of casket/container in which remains will be delivered:
Alternative Contaainer C (LO W A LD
PERSON IN CON OF DISPOSITION
(Person(s)in control of disposition, initial ONE of the fallowing)
I am/We are the designated agent of the deceased designated in a wig or written instrument executed
pursuant to Public Health Law section 4201.
iJWe have no knowledge that the deceased executed a written instrument pursuant to Public Health Law
se on 4201 or a will containing directions for the disposition of his or her remains and (Continued next page)
eI_vtti BYtA uM
00S-1M44 (Rev.01110) Name ofDeceased Page 1 of 3
MaV'0520,03:33p p.2
I 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:
(inse►t from the list below)
Number. Z Description: SPOUSE
1.A person designated in writing pursuant to Public Health Law section 4201(3);
2. 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 is/are 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 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§4201(7).
( THREE of the following)
tlWe hereby affirm that the body of the deceased does not contain a battery, battery pack,power cell,
inactive 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
Vtory personnel.
IIWe hereby affirm that instructions have been given to ffiWWWdrredorneme) Kammi kbod
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. (may nwwj Pine View Crematorium I 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
aftforemation.
UWe hereby authorize(aematorymm) P
a ns of the deceased. ine View Crematorium to cremate the
FINAL DISPOSITION
The person authorized to receive the cremated remains of the deceased from the crematory is:
Name:_(ZOSL1tq 'MmuM
Address: 15 Ag Uw L.1f a AoE tKL`ag t4 Y 112L1 a Phone:($ xq-3 37
The cremated remains of deceased will be disposed of as follows:
PESA t To FA (L%f
If for any reason the person named above does not take possession of the cremated remains,
(a„olmy na me) Pine View Crematorium is authorized to give possession of the remains to
(fu"W home rra►M) 1460 t� FU geMA, S£r tOU I ZMC. by delivery in person or by registered mail.
av(S
DOS-1 M44 (Rev.01110) Name of Dovnwd Page 2 of 3
Maya520,03:33p p.3
{ e following)
INVe understand that if the remains are not claimed within 120 days of cremation,
(awnallay nam) Pure View Crematorium may dispose of the remains in an irretrievable manner,
such as by scattering.
CREMATION CONTAINERIURN
(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:
I/We understand that if the um is too small to hold the entire cremated remains,an additional rigid container may be
used for delivery.
An urn has not yet been purchased. I/We understand that if no um is purchased or otherwise provided
wy ..) Pine View Crematorium will place the cremated remains in a rigid temporary
container for delivery.
This Authorization Form was provided by mmerafamdorname) P
was executed at tf xww borne name) 14600 FV ty L V -XN C
home address{) Ot 2tTt<L(%-( AV t t ZO 19 and is signed by the funeral director
as witness to its execution.
INVe have received a completed copy of this Authorization Form.
The persons)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.
Signed this l Sr day of MAY
R 3Llto 91w )KM UWifLkUVKj
Typed or P*ftd ffame '/
Ads AS o KLIN AvE gw Yo. �� I�
Typed or PnnW Name synahrte
Address
Typed or Printed Name Siynatwe
Address
WITNESS:
Kc=..t4NMX(4 1�009
Funeral Dkeator Typed or Printed Nerve Fwre+of Drreeba►Sigrrefure
IIto!t
Registravon Number
F. Svc A 91NUM
DOS-18W4 (Rev.01/10) Name of Deceased Page 3 of 3