Calderon, Justo V. Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: - i
- --� -- RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: s -_-_----_—
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
NAME: -------------
---
�(j�-_-
_._...__._---------CASE #
TYPE OF CONTAINER: -
PLACE OF DEATH: .
ESTIMATED WEIGHT OF REMAINS & CONTAINER
PLACED IN HOLD: _.__--.--.-__
PLACED IN REFRIGERATION:
- __._. -------_.----------------- _____
DATE OF CREMATION: --
TIME STARTED: ----------'-
- COMPLETED:
PLACED IN RETORT:
U Ph
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 CREMA
TORY.
I RX Date/Time 05/13/2020 09:46 15164136355 P,001
May 13 20 06:31 a Melford C. Everett 15164136355 p.1
New York State
Department of State
NEWYORK D�V�SIOR Of DIVISION OF CEMETERIES
STATE OF One Commerce Plaza
OPPORTUNITY. Cemeteries 99 Washington Avenue
Albany,NY12 2 31-0 0 01
Telephone:(518)474.6226
www.clos.ny.gov
Authorization for Cremation and Disposition
This Au ha ation Form must be completed and signed prior to delivery of remains for cremation.
1 I
Date: U` umber.,
Crematory Name: i
r
Address:
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
gontainer 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 DEC5A4EO
U , JjlJ Pc
Name of Deceased: ' Marital S Status:
r
Last Known A Tess: l� Q' ,� '\Kqt4
, L 0
TZ
Place of D the `�J
Sex: M ❑ F Age: DOB: Date of Death: Estimated Weight:
Description of ca on finer in trinsrllbedefiv�.4.
PER IN CONTROL OF DISPOSITION
(Pe tLawVecltion
ontrol of disposition,initial ONE of the following)
/We are the designated agent of the deceased designated in a will or written instrument executed pursuant to Public
Healt 4201,
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 pri ' and Publ' Health Law
jcWand ave the right to authorize cremation of the rem�jxs�the de eased_ My ur reI i shi o th dec"sed is as
(Name OeceasedJ
DOS-1898-f(Rev. 04/20) Page 1 of 3
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May 13 20 08;16a Melford C, Everett 15164136355 p,1
Authorization for Cremation and Disposition
(Insert fro a list below) 11
diva
9 � /�/,�Number: Description: 1i l I v L (y9—
1. A person designated in writing pu ant 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;
a. A duly appointed fiduciary of the estate;
9. A dose 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 ocher person who is acting on behalf of the deceased and who has executed a written statement pursuant to Public Health
Law Section 4201(7).
�HREE 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 cre at ry anal atory ers�nel.
I/We affirm that instructions have been given
rFurrraf f?ireCa Name)
regarding the removal of any perso I rop or�teI thing of value,nfhic�and yne�rso�nlU�Iowr any family member of the
deceased wishes to preserve. 1r h�V`�n,� 1iv �{�J�
(Crematory Mama)
not responsible for the removal of personal items from the container or from the remains of the deceased. Personal Items left in the
pCineror with the remains will be 4troyed he ere + zess
tf p ^and annot be retrieved after cremation.
I/We hereby authorize
(CrenaforyP me)
to cremate the remains of the deceased.
i'al OPTIONAL)
C 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 alternate crematory.
FINAL DISPOSITION � �
y The person authorized to receiv tii8 c7es%1pa V%?ff"M the crematory Is:
Name: 1flto*b%ICY 112M
w�e�giati�■1l4•prn Web-Sik
Address: Phone:
The cremated remains of deceased will be disposed of as follows:
If for any r pn t e person ed above doe'Moos take poss ion thl.cremated remains,
�L,�� is uI d to g' a Refs SS ion of
i f e1 II^^nn 1^J 7 r
(41
the remains to t ) )
ADwW Home Nam) e
in person or by registered mail. 1
(Name of 17eceaseOJ
DOS-1898-f(Rev.04120) Page 2 of 3
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May 13 20 06:27a Melford C.Everett 15164136355 P.1
Authorization for Cremation and Disposition
itial the lowing)
INVe unde I t/no at`if t re ai s are�n/o�t,clai ed vYd 'n 120 days of cremation,
f r 1L Vl/ A-n 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 um to be used as a container for the cremated remains has been purchased from
and is described as follows:
Me 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 i t yet purc ry se¢�'Me understand at if no um is purchased or otherwise provided
( 1 will place the cremated remains in
(Veme of Crematory)
a rigid temporary container for delivery,
This Authorization Form was provided by was executed at
1M4 PaeiBc Sited
(Funeral Home N
aes!eibEON0P yAi t �►
'Funeral Name 443-4%1 Offim
and is signed by the funeral director as witness to Its execution.
Me have received a completed copy of this Authorization Form.
The persons)identified below is/are the person(s)in control of disposition,who by signing this Authorization Form,attest($)
to the accurac4 4n mpleteness t information contained in this Authorization Form and authorize(s)the foregoing.
Si d this ` t\day of ,20 r
Typed or Panted Name �� � r ^� sign
1W►l 8�, � 1°�6'Z
A a��
Typed orPdnled Name Signature
Aodroas
Typed or Printed Name Signature
Addrs I
C '
(Funeral ie:lor Typed or PMted 61 (funeral Director S n m)
( egufraaon umbep
(Name or DeceasecQ
DOS-1898 f(Rev_04/20) Page 3 of 3