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Gonzalez, Epifania --6-6 14 Pine View Cemetery & Crematorium Quaker Road Queensbury, NY 12804 (518) 745-4477 or (518) 745-4476 FUNERAL HOME: _7Z _ __ RETURN TIME: DATE & TIME REMAINS ARRIVED AT CREMATORY: NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS: NAME: i �1 -- CASE # TYPE OF CONTAINER: PLACE OF DEATH: �` - •c��lua {'��/M ESTIMATED WEIGHT OF REMAINS & CONTAINER__________l�Q PLACED IN HOLD: PLACED IN REFRIGERATION: DATE OF CREMATION: — -0 zc) TIME STARTED: .__ (05-0 _,_TIME COMPLETED: — r PLACED IN RETORT: MOVED: 33Jm _ RETORT # IN WHICH REMAINS WERE CREMATED: _ © c, 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. t New York State Department of State NEW YORK D''V'S'O� O f DIVISION OF CEMETERIES STATE OF One Commerce Plaza OPPORTUNITY_ Cemeteries 99 Washington Avenue Albany,NY 12231-0001 Telephone:(518)4746226 www.dos.ny.gov Authorization for Cremation and Disposition This Authorization Form must be completed and signed prior to delivery of remains for cremation. Date: 04/28/2020 Number: Crematory Name: Pine View Crematory Address: 21 Quaker Road, 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 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: Epifania Gonzalez Marital Status: Divorced Last Known Address: 2343 Prospect Avenue, Bronx NY 10458 Place of Death: SJRH- St Johns Division, 967 N Broadway, Yonkers NY 10701 Sex: ❑M OF Age: 101 DOB: 07/28/1918 Date of Death: 04/25/2020 Estimated Weight: 150lbs Description of casket/container in which remains will be delivered. Thacker Casket Co- Cardboard constructed cremation container. PERSON IN CONTROL OF DISPOSITION (Person(s)in control of disposition, initial 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. -QR- 7 INVe 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.. Epifania Gonzalez (Name of Deceased) �a1C O�/�a 7 Pa DOS-1898-f(Rev. 08/15) 1 IZQSO��O _�� ge 1 of 3 Authorization for Cremation and Disposition (Insert from the list below) Number: 7 Description:Granddaughter 1. A person designated in writing pursuant to Public Health Law Section 4201i3). 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: 6. A lawfully appointed guardian. 7. Any person(s)eighteen years of age or older entitled to share in the estate and who is/aye 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 fiscal officer of a county or a public administrator appointed pursuant to the Surrogates 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). (tnrti I ALL THREE of the following) -INVe hereby affirm that the body of the deceased does not contain a battery. battery pack. power cell. radioactive implant. of radioactive device and that anv such materials were removed prior to the execution of this Authorization Form Failure to remove theseitems prior to cremation may result in harm to the crematory and crematory personnel. C, 1{IK-_ IM/e affirm that instructions have been aiven to John J. Sisto 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 Pine View Crematory is not responsible for the removal of personal items from the container or from the remains of the deceased. Personal items left in the contpiner or with the remains will be destroyed by the cremation process and cannot be retrieved after cremation. I Me hereby authorize Pine View Crematory �' rGenk;ror,F,�mC/ to cremate the remains of the deceased. FINAL DISPOSITION The person authorized to receive the cremated remains of the deceased from the crematory is: Name: Sisto Funeral Home, John J. Sisto Address: 3489 East Tremont Avenue Bronx NY 10465 Phone: 718 892-2102- The cremated remains of deceased will be disposed of as follows Please deliver ashes to Sisto Funeral Home, 3489 E Tremont Ave, Bronx NY 10465. Ashes will be returned to the granddaughter Alida Ortiz-Rodriguez If for any reason the person named above does not take possession of the cremated remains Pine View Crf r matory_ _ is authorized to give possession of (c7emaW Nana) the remains to Sisto Funeral Home by delivery .;FunEva!.4wne Name) in person or by registered mail Epifania Gonzalez !fame p:r)eeeasi ai DOS-1898-f(Rev. 08/15) 1k o5-piao—P4f 1CCq/Qa`1 Page 2 of 3 Authorization for Cremation and Disposition ✓(Inrti a the following) /`_"Jt_!�TANe understand that if the remains are not claimed within 120 days of cremation. / Pine View Crematory may dispose of the remains in an irretrievable manner. such as by scattering. CREMATION CONTAINER/URN (lnidal ONE of the following) An urn to be used as a container for the cremated remains has been purchased from Sisto Funeral Home and is described as follows: Me understand that if the urn is too small to hold the entire cremated remains. an additional rigid container may be used for delivery -OR- An urn is not yet purchased. IMIe understand that if no urn is purchased or otherwise provided _ Pine View Crematory will place the cremated remains in !Name c.'Cenrata.; a rigid temporary container for delivery. This Authorization Form was provided by John J_Slsto _ was executed at Sisto Funeral Home (runera!Hanle Name) 3489 East Tremont Avenue. Bronx, NY 10465 (F—eras r+unK Address! and is signed by the funeral director as witness to its execution. Me 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 author1ize(s)the foregoing. Signed this 28th day of April 20 20 / Alida Ortiz-Rodriguez TSPeo c,P-m!ed Ndrne 202 Timber Trail Court, Belair, MD 21014- ! tidd!ess 7ped c,Prared kanr_ ------ ------- 3•gna!a c. - WITNESS: John J. Sisto - fiC al Dp;-c.'c 7,;pa o,Prmxd N-1) ,e a'D•, eta _:at T 13334 Epifania Gonzalez (Name or Deceas ed) Tikos000--"0q/�/aa7 DOS-1898-f(Rev. 08115) Page 3 of 3 Operation Helping Hands Amendment Form Name of Funeral Home: 2STV i'V N8WAt- #Clt(C Manifest#: -- -aR US/QU— F q Gq Lcqk- Name of Deceased: & PL Ff4NIA, Gt(JNZ-&Z do hereby assign the above (Name of Funeral Director) human remains to the (State Name of Assigned Crematory and address): T/�Je W/C-U—) Gt1-q4'1Tjjq MOC &A US9XY A Upon completion of the cremation process,the crematory is to send the cremated remains to: (S X0 a 7- Avc- &olix, �D ignature cVuneral Director Date