Copersino, Jean Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME:
� `------- -- - _ RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: /
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
NAME:
- ---__ ------------ -__CASE # -_�3
TYPE OF CONTAINER: q6 jz
PLACE OF DEATH:
ESTIMATED WEIGHT OF REMAINS & CONTAINER 2-
PLACED IN HOLD:
PLACED IN REFRIGERATION: -
DATE OF CREMATION: ---
TIME STARTED: _ �;
COMPLETED: ID;JS_
PLACED IN RETORT:
------ 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.
New York State
Department of State
NEW YORK D'V'S�O�"t Of DIVISION OF CEMETERIES
STATE OF One Commerce Plaza
OPPORTUNITY. Cemeteries
`erles 99 Washington Avenue
Albany,NY 12231-0001
Telephone:(518)474.6226
wwW.aos.ny.yuv
Authorization for Cremation and Disposition
This Authortzation Form must be completed and signed prior to delivery of remains for cremation.
Date:4/28/2020 Number: 613
Crematory Name: oe V Q W AU r
si
Address: -e-e n 5 Phone: 7y5 Z/y 7
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS
Cremation is carried out by placing the remains of the d and the container holding the remains into a cremation chamber where
they are subjected to intense heat and flame. The heat and filsme will incinerate and consume everything except bone and metal,
which are aN that will be IsR~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 remakhs 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 pulvertsed until no
single fragment is recognizable as skeletal tissue.
OPENING OF THE CONTAINER
The crematory may only open the container holding the un mated human remains in limited circumstances.such as to confirm the
identity of the deceased or to ensure that no material is andnim which might injure employees or damage the crematory property. N
human remains are delivered in a container which is notJ unablem
for cremation such as ceremonial or rental ca*kK the
crematory wily require that the remains be moved into a s Itable container before it accepts the remains. The opening of a
container or the transfer or removal of remains will be conduc d before a witness and will be done In privacy,Witt dignity and resort.
IDENTIFICATION OF DECEASED
Name of Deceased:Jean Copersino Marital status: Widowed
Last Known Address:707 Throm Neck expM New York, New York 10465
Place of Death:Thr s Neck Extended Care
Sex: ❑M ®F Age:89 Dos:6/11/1930 Date of Death:4/23/2020 Estimated weight.
Description of caskettcontainer in which remains will be delivered.
Matthews Intemational Casket Company Uni n Cloth Covered
pEgSON IN CONTROL OF DISPOSITION
(Pemon(s)to c:onhW of cli4m ldon,In bat ONE of the lWowing)
I am/We are to designated agent of the deceased designated in a will or written instrument executed pursuant to Public
Health Law Section 4201.
UWe have no knowledge that the deceased exec a written instrument pursuant to Public Health Law sediorh 4201 or a
d&ecliona for the disposition of his or her rem�rns and Uwe are the persorh(s)havirhg priority under Public FIQeiBh Law
Section 4201 and have the right tc authorize cremation of thla remains of the deceased. MylOur relationship to the deceased b ss
follows:
Jean Co ersino
cwm. wa..•ro
' DOS-18W4(Rev.08115) Jean Copersino
Schuyler Hill Funeral Home
TR050120_FH06/C09/044
Authorilation for Cremation and Disposition
(Insert from the list below)
Number:3 Description:daughter
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 dtid eighteen yam 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;
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 Section 4201(7).
(ON ALL THREE of the Wowing)
Me 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 Autfrorhadon Form. Failure to remove
these Items prior to cremation may result in harm to the crematory and crematory personnel.
*a L�—Vwe affirm that instructions have been given to TOnl Ann Cicalo
ro.
9-V (F„asrn.xwam.)
regarding the removal of any personal property or other thing o value which any person signing below or any family member of the,
deceased wishes to preserve.
(crrnerory Nrm.J
is not responsible for the removal of personal items from the container or from the remains of the decea Pereonal Items left in the
container or with the remains will be destroyed by the crornation process and cannot be retrieved after cremation.
Lu
e hereby authorize "
i
(GWWWY NOM)
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:Schuyler Hill Funeral Home
Address:3535 East Tremont Avenue Bronx New York, 10465 Phone:718-792-0270
The cremated remains of deceased will be disposed of as follows:
Give to a funeral home rep to return to the faTily If for any reason the person named above does not take possessionA the cremated ins.
(;( G r is authorized to give possession of
(CnmNory Nang)
the remains to Schuyler Hill Funeral Home by delivery
(Famntl Nana)
in person or by registered mail.
Jean Cnnprcinn
Jean Copersino
DOS-18Wf(Rev.08115) Schuyler Hill Funeral Home
TR050120_FH06/C09/044
Authorization for Cremation and Disposition
(J�j�l the following)
( e understand that if the remai are not claimed!within 120 days f cremations
r
ay dispose of the remains in
INan.or c-wyl
an irretrievable manner.such as by scattering.
CREMATION CONTAINERIURN
(ft ft ONE of the following)
An urn to be used as a container for the cremated remains has been purchased fromand 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.
SIC urn is n t purchased. IIWe understand t I if no um is pur or otherwise provided
f)t C O t 1 (� —C will place the cremated remains in
- -- —Vc1_ �-.
a rigid temporary container for delivery-
This Aufhorization Form was provided by Toni Ann CicalO ____ _ was executed at
/Fun.w Olreuo,Nana)
Schuyler Hill Funeral Home_-_ —
(F,nNa Naar N-
3535 East Tremont Avenue, Bronx, Neu York 10465 _____
(F NOm.AdonrW
and is signed by the funeral director as witness to its execution.
tMe have received a completed copy of this Auttwrization Form.
The person(s)Identified below Were the person(s)In control of disposition,who by signing this Aufborizadon Form,alings)
to the accuracy 9nd completeness of the information cootaMed In 1hls�AutAo`1 rizatlon Form and authorlria(s)the forogOkV•
Signed this day of
C7�1,v)
Ginamarie Yonkus
Tywwp~W n.
146-44 25th Road, New York New Yor�C 11354 ,
AWN" -
rypdvnr.�d
WITNESS:
Toni Ann
(FunaY DN+Oer 7ypM w Killed Nam)
Jean Copersino
Page 3 of 3
DOS-1898-f(Rev 08115)
Jean Copersino
Schuyler Hill Funeral Home
TR050120_FH06/C09/044