Dickerson, Edward Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: _EVe� �� � vJ�,,[
RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: . :/y.�zp
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVER
REMAINS:
NAME:
TYPE OF CONTAINER: -_4finiV�'
PLACE OF DEATH: ----�'!- _7 l; IVYNy Q-Z j_-
11..._.
ESTIMATED WEIGHT OF REMAINS & CONTAINER.-.-.-,_
PLACED IN HOLD: Tl
PLACED IN REFRIGERATION:
DATE OF OF CREMATION: .S--15- - 'Zp
TIME STARTED: --`Z lS ^
COMPLETED: -
PLACED IN RETORT: �-yS �,•I
RETORT # IN WHICH REMAINS WERE CREMATED:
-------Pam
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SHALL HE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
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New York State
Department of State
NEW YORK DiVISIOR Of DIVISION OF CEMETERIES
STATE Of One Commerce Plaza
OPPORTUNITY. Cemeteries 99 Washington Avenue
Z. Albany,NY 12231-0001
Telephone:(518)47"226
www.dos.ny.gov
Authorization for Cremation and Disposition
This Au hoc' tion Form must be completed and signed prior to delivery of remains for cremation.
r �
Date: Number i �n
Crematory Name: I Iv 0-A I L�U
/�
Address: i� PLO K
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 wilt 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 generalty 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
pontainer 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 S D W n 6V (�
Name of Deceased: �C Aarju Status: / �7
Last Known Address d �v" vw r`� l V lL
Place of De
Sex: 1 0 F Age: DOB: -Z�Date of Death: Estimated Weight: /!5'D
Description of ce ont mer in which ns yril�deliv d. _,� F� O
PE IN CONTROL OF DISPOSITION �J
i
s in control of disposition,initial ONE of the following)
1 mMe are the designated agent of the deceased designated in a will or written instrument executed pursuant to Public
Law 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 and 11we are the p rson(s)having priority under Public Health Law
and have the right to authorize cremation of the remains oft c sed. Myl?Our r ati ship tttt�he�de/ecceased, is as
fo o s: 9 �l�' ' ✓�� ,A
�[y
(Name vrDe�Besed]
DOS-1898-f(Rev. 04120) Page 1 of 3
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Authorization for Cremation and Disposition
(Insert from a list below) Q ' / r/i'"1 �� `1 zd�A
i(dxg ok rNumber: Description: r i" f V �"�r (Y
1. A person designated in writing pur uant 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;
8. 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 other person who is acting on behalf of the deceased and who has executed a written statement pursuant to Public Health
Law Sec ion 4201(7).
( i HREE of the following)
Me 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 priorto the execution of this Authorization Form. Failure to remove
ems prior to cremation may result In harm to the cre71�=atoyersorP Y
Me affirm that instructions have been given to
(Funeral Direc(orNams)
regarding the removal of any personal prop rt or other thin Kalue which any FQrSAOn signing belo or any ammily member of the
deceased wishes to preserve. t f L�, �' ((Crematory Name)
not responsible for the removal of personal items from the container or from the remains of the deceased. Personal items left In the
c iner or with the remains will be s�rtro ed hQe c�re� ti �(c}esr"andann ot beretrieved after cremation.
I/We hereby authorize ` Q� L' w
(Crematory me)
to cremate the remains of the deceased.
Ir 'al OPTIONAL)
1/we hereby authorize the named funeral director to provide for delivery to and cremation by an alternate
cr ,it deemed necessary in the opinion of the funeral director,and to amend this form to provide the correct name and
addr ss of such attemate crematory.
FINAL DISPOSITION �n�tt
The person authoraed to receivFttfe c�esrr =a � Sf'67h the crematory is:
Name: keekbis.i�.Y
owes We►Ift
Address: u�443 �f!: Phone
The cremated remains of deceased will be disposed of as follows:
�. 41i'oO iK Od,
If for any r n t e person Cy fed�'�ab-Iov,,e'doe o take oss ion the�cremated remains,
1� v ( &V� is uth d toy ion of
le 1v
the remains J d e)ve to 1�
• (Fune f Home Name)
in person or by registered mail. V!`-Y
jName c Deceased,'
DOS-1898-f(Rev.04/20) Page 2 of 3
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Authorization for Cremation and Disposition
In'' a following)
Me unde no that if t re a4sare not dai ed withjr�0 days of cremation,
1j)� /�"/IIG�L (��•/( may dispose of the remains in
(Name of Lremetay)
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 n t yet purchase9� INVe understand at if no um is purchased or otherwise provided
l will place the cremated remains in
(Name of cremslory)
a rigid temporary container for delivery.
This Authorization Form was provided by Mull
was executed at
Ind PWAC Skid
(Funeral Home
(Funsmf Home "3.
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 Ware the person(s)in control of disposition,who by signing this Authorization Form,attest(s)
to the accurac in mpleteness th information contained in this Authorization Form and authorize(s)the foregoing.
r
S' this ay of 20
Vented N I signs
X to 0,-S 0
Address
Typed or PdrRed Name Signature
Address
Typed orPrfn red Name Signature
Addres
wl ss:
(Funeral iecforTyped orPnntBd Nglnr� l� (Funeral Drreclor S n )
(Name&Deceased)
DOS-1888-f(Rev.04/20) Page 3 of 3