Payne, Clifton Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: _ llk(&
RETURN TIME:
ATE 8, TIME REMAINS ARRIVED AT CREMATORY: - --
NAME OF FUNERAL DIRECTOR OR REG RISTERED RESIDENT DELIVERING REMAINS:
NAME:
CASE #
TYPE OF CONTAINER:
PLACE OF DEATH: ._
-----.--..--._-
ESTIMATED WEIGHT OF REMAINS & CONTAINER-_...
PLACED IN HOLD; -
PLACED IN REFRIGERATION:
DATE OF CREMATION: ---------- ..- --- - -..._..-- - ------- _-- --
-- -- - - 5 /&IZa
TIME STARTED: 60
---- _------ .TIME COMPLETED: 7
PLACED IN RETORT:
1
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
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New York State
Department of State
NEW YORK Division of DIVISION OF CEMETERIES
STATE OF One Commerce Plaza
OPPORTUNITY_ 99 Washington Avenue
Cemeteries Albany,NY'12 2 31-0 0 01
Telephone:(518)474-6226
www.dos.ny.gov
Authorization for Cremation and Disposition
This au on anon Form must be completed and signed prior to delivery of remains for cremation.
��JDate: 1 '1 umber:.
Crematory Name:
Address: - u Fl on�
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 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 DECEASE
D - I
Name of Deceased: N N Mar I tatus:� a
Last Known Addr s:
Place of De h,
f le l CZ/
Sex: M Q F Age: B: ( v r Date of Death: 113 L O z 0 Estimated Weight
Description of ca oJine r in which r ns yvill be deliv ( ��
OK
PE'i IN CONTROL OF DISPOSITION
(Pe' sin conlrol of disposition,inilJal ONE of the following)
I m/We are the designated agent of the deceased designated in a will or written instrument executed pursuant to Public
Health Law ection 4201.
e have no knowledge that the deceased executed a written instrument pursuant to Public Health Law Section 4201 or a
Jc
n g irections for the disposition of his or her remains and I/we are the erson(s)having n?nty under Public Health Law
and have the right to authorize cremation of the remain f se "Urtionship to the deceased is as
S.
�
(Name of De eassa)U
DOS-1898-f(Rev.04120) Page 1 of 3
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A horization for Cremation and Disposition
Ini I t e following)
I/We unde t/notat� re 'i s are not clai ed wi 'n 120 days of cremation,
L - � � may dispose of the remains in
It (Name or Crematory)
an irretrievable manner,such as by scattering.
CREMATION CONTAMERIURN
(1nitial 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:
1 e understand that if the um is too small to hold the entire cremated remains,an additional rigid container may be used for delivery.
O -
An urn is n t yet purchase¢, Itwe understand at if no um is purchased or otherwise provided
T i (�' z1 1 will place the cremated remains in
k� V (Name or cremeto y)
a rigid temporary container for delivery.
This Authorization Form was provided by Ev"WKa US was executed at
if"Pacific Sheet
(Funeral Home Ne _`�
Wits
'Funeral Hone 4rM
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 accurac n mpleteness thA Information contained In this Authorization Form and authorize(s)the foregoing.
Si ed this ftV of �}l/ "v .20 v
T P led r;,,��J� \�{./ ��p �� • f �
Address
Tyoed or Printed Alamo Signalura
Address
Typed or NNW Name Signaiure
Addret
(Punce'l
rTypado'Pn'nledN (Funeral0ireclor5 n ro)
( gistralicn NvmOer) ^
(
tNarrro orDeeeesed)
DOS-1838-f(Rev_04/20) Page 3 of 3
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Authorization for Cremation and Disposition
(Insert fro r e 1 si below) fi��A'V)
1�
Number: Description:
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;
S. 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/are closest in relationship to the deceased;
S. 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 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).
TNREE of the following)
I/We 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
ems prior to cremation may result in harm to the crem ry a m&aryersoyrfi>�I.
` Me affirm that instructions have been given to
(Funerd OheUarName)
regarding the removal of any personal prop or other thing value
,w�hii�h any a so\si nin�ow or r idly member of the
deceased wishes to preserve.
(Cremarary Name)
not responsible for the removal of personal items from the container or from the remains of the deceased. Pe onal Items left in the
*nIneror with the remains will be stroyed a crem itpM�nd annot be retrieved after cremation.
We hereby authorize ! ' " - P`t w
atwy e)
to cremate the remains of the deceased.
ni al OPTIONAL)
Ilwe hereby authorize the named funeral director to provide for delivery to and cremation by an alternate
cr ,if deemed necessary in the opinion of the funeral director,and to amend this form to provide the correct name and
addr ss of such altemate crematory.
FINAL DISPOSITION ��
The person authorized to receivf ffiL cze-m%V4 ai YW11M.%%the crematory is:
Name:_ Breeklm H'Y 112M
Ww
Address: Phone:
The cremated remains of deceased will be disposed of as follows:
Oro
If for an r pn t e erson ed above doe take_ poss on thg cremated remains,
y ! is uth6 d to a ion of
I b de,{f r,
the remains to
• (Fu al Home Name) `
in person or by registered mail. N
/Name I Deceased)
DOS-18984(Rev.04120) Page 2 of 3