Washington Jr,.Willis Cephus Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: -�r
RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: S-/y•-�� r 3��
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DEL
IVERING REMAINS:
NAME:
# p
TYPE OF CONTAINER:
PLACE OF DEATH: ._rlo S��
ESTIMATED WEIGHT OF REMAINS & CONTAINER___ �g4
--�b -------5�1L.�-19_Z_Jh
PLACED IN HOLD;
PLACED IN REFRIGERATION:
DATE OF CREMATION: -
TIME STARTED: COMPLETED:
PLACED IN RETORT: a_ f �� !,—
----MOVED: S G6D
RETORT # IN WHICH REMAINS WERE CREMATED: ____
_-o �1 1
i t,, t/'/DZ,/l.� Pet,L c
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 CREMATO
RY.
RX Date/Time 05/11/2020 12:00 15164136355 P,001
Flay 11 20 08:46a Melford C. Everett 15164136355 PA
New York State
Department of State
NEWYORK D'ViS'On O DIVISION OF CEMETERIES
STATEOF One Commerce Plaza
OPPORTUNITY_ Cemeteries 99 Washington Avenue
Arbany,NY12 2 31-00 01
Telephone:(518)4746226
www.dos.ny.gov
Authorization for Cremation and Disposition
This Au on ation Form must be completed and signed prior to delivery of remains for cremation.
I
Date: 0 umber., r�--7
Crematory Name: i
r
Address: �� i P on .
r
CREMATION IS AN IRREVERSIBLE AND FINAL PRO rESS.
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.
i Following cremation,the crematory will take reasonable efforts to remove all of the remains and other material from the cremation
I 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 um. 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 wit!be onducted before a witnes and will be done in privacy, with dignity and respect.
IDENTIFICATION OF Di= Sf (�
Name of Deceased: C ! ial St u I
Last Known Ad s S.
r - /� ,
Place of D the �� J S v' il r
Sex: M 0F Age: DOB: Date of Death: Estimated Weight C ��•t�,
Description of Ca n mer n which r ains ril a deliv
/,�J 0y,
PE IN CONTROL OF DISPOSITION
(Pe s ntrot of disposition, initial ON of the following)
I m/We are the designated agent ofthe deceased designated in a will or written instrument executed pursuant to Public
Healt aw ecdon 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 I/ a are the per s)having priority and Public 1-
so h Law
c and have the right to authorize cremation of the r/� ains f e de ased MylOnur relationship oJthe dece he is aass
fo
( cf De sed)
DOS-1898-f(Rev.04120) Page 1 of 3
Rk Date/Time 05/11/2020 12:05 15164136355 P,001
May 1120 08:51a Melford C. Everett 15164136355 p.1
Authorization for Cremation and Disposition
(Insert fro the list below)
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 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;
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 Se ion 4201(7).
( ill �L 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 radioactiv device and that any such materials were removed prior to the execution of this Authorization Form. Failure to remove
t7l
prior to cremation may resultin harm to the crem i ry anti mato pernel./We affirm that instructions have been given to
(Funeral DAedorNeme)
regarding the removal of any personal s 1per or oth r)hing of value�+ivh'ch any person i bet ow
or any family member of the
deceased wishes to preserve.
(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 liner or with the remains will be dldstroyed h(e�cjr�e,(nf tit[4cessand annot beretrieved after cremation.
I/We hereby authorize ` ' �
(crematory e)
to cremate the remains of the deceased.
i'al OPTIONAL)
I/we 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 funera[director,and to amend this form to provide the correct name and
addr ss of such alternate crematory.
FINAL DISPOSITION The person authorized to receivfi"c e,m%j a MWA1WWffi the crematory is:
Name: Sreekillb MY.II=
fw vudm- A J910 6 w Welt
Address: u�"3_I"i om Phone:
The cremated remains of deceased will be disposed of as follows:
If for any r" f;pn t e person ed above doe¢�tot�ke poss ion thlc(rejmated remains,
— is utho ' d to gi�e R 1s ion of
Othe remains to ? "Al' "
• (Pone I Home N J�
in person cr by registered mail. UV
,
' (Name o,Dece edJ
DOS-1898-f(Rev.04120) Page 2 of 3
RX Date/Time 05/11/2020 12:07 15164136355 P.001
May 1120 08:54a Melford C. Everett 15164136355 p.1
Authorization for Cremation and Disposition
I F
ng)
unde I t/no}tat if thl re ai s are not dal ed wi 'n 120 days of cremation,
Vw K A-
may dispose of the remains in
(Name or crematory)
an irretrievable manner, such as by scattering.
CREMATION CONTAINER/URN
&M ial 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:
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.
O -
An um is n t yet purchaseA Me understand at if no um is purchased or otherwise provided
A 1' will place the cremated remains in
y f! (hame of crwklory)
a rigid temporary container for delivery.
This Authorization Form was provided by a fwas executed at
104 PSCM Suld
{Funeral Home
xunerel Hume/f r(#M 40-f%j .
and is signed by the funeral director as witness to its execution. ` __l
[Me have received a completed copy of this Authorization Form.
The person(s)identified below Isiare the person(s)in control of disposition,who by signing this Authorization Form,attest(s)
to the accurac n&gZmpleteness o,Qjth information contained in this Authorization Form and autho e(s}the foregoing.
S;1j
y of 20 r'
L
T. PnnledNa re aw
o o!
Address
Typed or Prow,Name Sigrtelure
Address
Typed or Prtnted Name Signature
Addre
WI �S�
(funeral freclor Typed or Pn'nled A' (Funeral iAve
)
(RegislraUon NumOer)
(Name ofDeaeased)
DOS-1898-f(Rev.04/20) Page 3 of 3