Lynch, Vincino Arlene Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: U �Li � - �UF�t+(,y- - - -
RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY:
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
NAME: ------—CASE #
TYPE OF CONTAINER: _....___.C°✓-
PLACE OFub..._—
ESTIMATED WEIGHT OF REMAINS & CONTAINER 'ZZb
I
PLACED IN HOLD;
PLACED IN REFRIGERATION:
DATE OF CREMATION:
TIME STARTED: __-- ------ ---TIME COMPLETED:
PLACED IN RETORT: 'Uo
--- ------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.
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New York State
Department of State
NEWYORK Q�V�sIOR 0f DIVISION OF CEMETERIES
STATE O F One Commerce P1a22
OPPORTUNITY_ 99 Washington Avenue
Cemeteries Albany,NY 12 231-0 0 01
Telephone:(S18)474-6226
www.dus.ny.gov
Authorization for Cremation and Disposition
This Au on tion Form must be completed and signed prior to delivery of remains for cremation.
Date: umber, o
Crematory Name: (��� I ' L�'U`
Address: _ P onb: 0, '
CREMATION IS AN IRREVERSIBLE AND FINAL PRO ESS.
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
rpntainer or the transfer or removal of remains will be conducted before a witness and will be done in privacy,with,�ij�'{[y��d re
IDENTIFICATIO N OF DEC r A '�/'vp
zti 00 otLp� NC,
Name of Deceased: �arital Stat s.
Last Known Add ss: f/0. l
Place of Death: ti �\ l A
Sex: 0 M F Age: DOB: Date of Death: Estima d Weight: —Z 10
� I
Description of ca on Iner in which r ns yvilll e�defi4ri6d. !�
PlEllkS IN CONTROL OF DISPOSITION
(Pe s - rol of disposition,initial ONE of the following)
I m1We are the designated agent of the deceased designated in a will or written instrument executed pursuant to Public
Health aw ection 4201.
I e have no knowledge that the deceased executed a written instrument pursuant to Public Health Law Section 4201 or a
n n g irections for the disposition of his or her remains an Itwe are the person(s)having priority under Public Health Law
c and have the right to authorize cremation of the re s of the deceased. M ur re tionship to th deceased' as
� Loi nfo o s; o � C
v '" (Name orDaceesedJ
DOS-1898-f(Rev.04120) Page 1 of 3
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Authorization for Cremation and Disposition
(insert fro a fist below
( ) #/U
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;
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 Ware 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 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 Se lion 4201(7).
( f NREE 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 radioactiv 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 a ry an repmat p sonn�N �I
Me affirm that instructions have been given to
�L � (. �
(Funeral DlrecWName)
regarding the removal of any person Koperty or Ctpe.r thing of v hich any per n gping below or any family member of the
p
deceased s to wishes
wi reserve.
(crema(ory Name)
*61 not responsible for the removal of personal items from the container or from the remains of the deceased. Personal items left in the
c n iner or with the remains will be st(rooy h�e cJreJ tf p cce�ss^and annot belrletrieved after cremation.
We hereby authorize '< ' " `k ti `-"�` `� w
J
(/ilOmalW} BI
to cremate the remains of the deceased.
i 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 alternate crematory.
FINAL DISPOSITION The person authorized to receiv i cr e,smdalt=§WA!Iteft the crematory is:
Name: PT41, ea N.Y l =
ever v1A srwty#w*Web-BiMi
Address: , INS OEm Phone:
The cremated remains of deceased will be disposed of as follows:
If for any r Pn a person ed above doeoE MV puss ,ion thel`cremated remains,
7 C' fj` , J
is ut m �d to iqe peg-ge�S ion of
the remains to ,del( rr
• (Funs I Nome Na a r /',
in person cr by registered mail. r q / 3 V
Mamled Deceased)
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Authorization for Cremation and Disposition
itial th folio ing) /
111Ne and no that if the)re fai s are not clai ed�"n 120 days of cremation,
may dispose of the remains in
' (Name OfCremetory)
an irretrievable manner,such as by scattering.
CREMATION CONTAINEIRJURN
(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:
iNJe understand that if the urn is too small to hold the entire cremated remains,an additional rigid container may be used for delivery.
-O
An um is n t yet purchase A IIV1/e understand at if no um is purchased or otherwise provided
ijwill place the cremated remains in
y 1V (Abma of crematory)
a rigid It mporary container for delivery.
This Authorization Form was provided by was executed at
16�i1 RtiSc Sh+taet
(Funeral Nona N
17� "W Wtaa�ile
(Funerd Hama Aitt\'p)"3-
and 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,attest(s)
to the accurac n mpleteness th information contained innf this Authorization Form and authorize(s)the foregoing.
Siin ned th day of C�� ,20
Rpn
rynkmCnr Prtn Hato
o F 9 -
Address
Typed or Pr"ed Name Signnlum
Address
Typed orPdnted Name S/ynatme
r
Addres
WI
(Funcmf OimGv Typed ar FNNed N�ne�� �/)� (Funeral Oirecfor )
(egrstrationWjrnw)
J I s
, 7
(Name of Deceesea)
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