Craig, Frances Rose Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: T(�(m � '
- �----�U�' __.___ RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: ���`� j'
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
NAME: -
CASE #
TYPE OF OF CONTAINER:
------------- l_ w4 _ . - �b�.
PLACE OF DEATH: -- ----���------J!•���----....._...I'�'-°y��-!-�L-------1"��-----
--..._._.-..__-.-.-_..-------
ESTIMATED WEIGHT OF REMAINS & CONTAINER_-._.__
PLACED IN HOLD:
PLACED IN REFRIGERATION: -
DATE OF CREMATION: S
TIME STARTED:
PLACED IN RETORT:
---------------�=-��f�f--.____._____.TIME COMPLETED:
--- ---�.L MOVED:
6'
--- ---- - - P _2._z_o
Aj
RETORT # IN WHICH REMAINS WERE CREMATED: I
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
-RX Date/Time 05115/2020 05:13 15164136355 P,001
May 15 20 01:58a Melford C. Everett 15164136355 P.1
New York State
Department of State
NEWYORK pivision of DIVISION OF CEMETERIES
STATE OF one Commerce Plaza
OPPORTUNITY_ Cemeteries 99 Washington Avenue
Albany,NY12 231-0 0 01
Telephone:(518)4746226
www.dos.ny.gov
Authorization for Cremation and Disposition
This Au orl anon Form must be completed and signed prior to delivery of remains for cremation.
j �35Date: � \ umber..
Crematory Name: 1 l '''`� "u / _
gg P on�. G4
Address: 'I
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 DEC ,
Name of Deceased: Q�tr Marital Stat
Last Known Address: to l D
AJf n
Place of Death: f' ^ I )
Sex: ❑M F Age:_ DOB: � 7 Date of Death: �t`,h, Estimated Weight: �L)
Description of ca e n iner in which r ains ill e deliv d.
PE IN CONTROL OF DISPOSITION
(Pe s in control of disposition,initial 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
Healt .Law ecbon 4201.
Wand
ave no knowledge that the deceased executed a written instrument pursuant to Public Health Law Section 4201 or a
tions for the disposition of his or her remains and Uwe are the person(s)having priority under Public Health Law
cave the right to authorize cremation of the remains of a deceased. MylOur r tionshipto the deceased is as
fo1 o
vl•r r (Namecic0-e'ceesec� W
Pagel of 3
DOS-1898-f(Rev.04/20)
RX bate/Time 05/15/2020 05:03 15164136355 10.001
May 15 20 01:49a Melford C. Everett 15164136355 p.1
Authorization for Cremation and Disposition
( ial the l Mowing)
I[/We unde t no at`if,t re ei s are�nnot,clai ed i 'n 120 days of cremation,
1 W may dispose of the remains in
(Name of Cremelory)
an irretrievable manner,such as by scattering.
CREMATION CONTAINER/URN
(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 um is n t yet purchase Me understand at if no um is purchased or otherwise provided
T ° '1j 1 will place the cremated remains in
Il l (Name of Cremaroryl
a rigid temporary container for delivery.
This Authorization Form was provided by Zvermwas executed at
1@i4 Ptd&Sheet
(Funeral Hame Na
ees>leltb4awri17!`.ta+�W�-bite
;Funeral Home'T"n
.pnd 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)identified below Is/are the person(s)in control of disposition,who by signing this Authorization Form,attests)
to the accurac n Impleteness th Information contained in this Authorization Form and authorize(s)the foregoing.
Ur
Signe this day of 20
CY�_;(7
Typed or 05Anfed Name { I DST signature N>Lv ��L4,
_Z �AX
Address
Typed or Prirtletl Nerve Signs uoe
Address
Typed or Printed Name Signalure
Addre
IIVI SS:
(Funeral red or Typed or PriNed h'� �'1 � (Funeral DireGor S ref
(Repislra En Number)
(Nato.ofUecaasedl
DOS-1898-f(Rev. 04/20) Page 3 of 3
RK Date/Time 05/15/2020 05�06 15164136355 P.001
May 15 20 01:53a Melford C, Everett 15164136355 p,1
Authorization for Cremation and Disposition
(Insert from the list below) n 1 c f r O/1 40 delo,
Number. Description: ' t`� , ��1 j Jv v
1. A person designated in writing 4rsuant 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;
6. 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. 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;
1 Da. 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).
( rti REE of the following)
IJWc 11rl cby dfltlllt 11Idt lilt:burly of tl]c JCUCa:jcJ Joe-3 not contain a battery,battery pack,power cell,radioactive implant,
ur radivau;tive device and tliat 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 crematory and rem,/ perso el.
t
We affirm that instructions have been given o (FunrlarUi,edorNarne)
regarding the removal of any personal pro or other h" got value Ihich rson signing be ow or any family member of the
deceased wishes to preserve.
(cmmelory Name)
not responsible for the removal of personal items from the container or from the remains of the deceased. Personal items left in the
pnineror with the rematns wIB be troyed he cretrj tigr�p cess and annot be retrieved after cremation.
I/We hereby authorize
(Gematary me)
to cremate the remains of the deceased.
n
i al OPTIONAL)
I1we hereby authorize the named funeral director to provide for delivery to and c►emation by an alternate
or ,H deemed necessary in the opinion of the funeral director,and to amend this form to provide the correct name and
add ss of such alternate crematory.
FINAL DISPOSITION w.MC on%jV'K'jr1W%AWM�1a"The person authorized to receivfftT�czeTrOxr the crematory is:
Name: f111OW1 Ity.11238
Address:
� Phone:� � �
The cremated remains of deceased will be disposed of as follows:
Cl
1A Tt �� k
If for any r n t e person ed above doe of take poss ion the cremated remains,
p G'
,\ �•t, is uthoi d to i e i ion of
dv� �Y
the remains to
in person or by registered mail.
(Name a/b sod)
DOS-1898-11(Rev.04120) Page 2 013