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Smith, Marilyn 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: NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DEL f IVERING REMAINS: NAME: -y �S fn i ------------ —casE # TYPE OF CONTAINER: LL G PLACE OF DEATH: 17 ' ESTIMATED WEIGHT OF REMAINS & CONTAINER_-,..- PLACED IN HOLD; PLACED IN REFRIGERATION: DATE OF CREMATION: _ TIME STARTED: ------f--------- -- - _TIME COMPLETED: PLACED IN RETORT: - 7�/p MOVED: ---- 1p - _ - --- RETORT # IN WHICH REMAINS WERE CREMATED: DETAILED REASON FOR DELAY IF R EMAINS 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. AX Date/Time 05/15/2020 09:18 15164136355 P,001 May 15 20 06:03a Melford C. Everett 15164136355 p.1 New York State Department of State NEW PORK Division Of DIVISION OF CEMETERIES STATE OF One Commerce Plaza OPPORTUNITY. Cemeteries 99 Washington Avenue Albany,NY12 231-0 0 01 Telephone:(518)474-6226 www.dos.ny_gov Authorization for Cremation and Disposition This Au on anon Form must be completed and signed prior to delivery of remains for cremation. Date: + umber:,I Crematory Name: Address: i W CREMATION IS AN IRREVERSIBLE AND FINAL PRO S. 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 wilt 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 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 remalns 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 will be conducted before a witness and will be done in privacy,with dignity and respect. IDENTIFICATION OF DECEA6EQ Name of Deceased: �t< r v�/ i'``' arit Status. w ` Q%7` Last Known Address: C ~'r"' e Kick n / Place of Deaar th: , !,! t �s 36 Sex: Elm F Age: DOB: *� Date of Death: Estimated Weight: Description of ca� ont Iner in which r ains#1111 be deliv PE %Law ONTROL OF DISPOSITION (Pe• ontrol of disposition,initial ONE of the following) m/We are the designated agent of the deceased designated in a will or written instrument executed pursuant to Public Healction 4201. K�X_ VIAMN. ave no knowledge that the deceased executed a written instrument pursuant to Public Health Law Section 4201 or a �Sc irections for the disposition of his or her remains and Ilwe are the persons)h ving priorit under Public Health Law d have the right to authorize cremation of the remains of th de eased. Mytoeceased is as f (Name aDeceased) DOS-1898-f(Rev.04120) Page 1 of 3 RX Daf,ITime 05/12/2020 06:45 15164136355 P,001 May-12 20 03;31 a Melford C, Everett 15164136355 p.1 Authorization for Cremation and Disposition 11 (Insert fro he Gst below) 0 6� Number: Description: l� 1. A person designated in writing Itursuant 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 Section 4201(7). r � ( i( HREE of the folio win 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 Authorization Form. Failure to remove �'tkte �'ems prior to cremation may result in harm to the cr;Ta�ry ary�Cremat�ry�rsonne� ,�• ` ram'-il, Lam. UJ P I/We affirm that instructions have been given to (FunerafOireUor Nam e) regarding the removal of any personal p �ty or oth r �ng off,vallue w y person si nin blow or any family member of the deceased wishes to preserve. —V" M (Crematory Name) j not responsible for the removal of personal items from the container or from the remains of the deceased. Personal items left In the } cf l finer or with the remains will be troyed he crer p ti cess and annot be retrieved after cremation. Me hereby authorize \ (Crematory me) to cremate the remains of the deceased. J'aI OPTIONAL) 1/we hereby authorize the named funeral directorto provide for delivery to and cremation by an alternate or ,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 Vf&Pj�'d� 7� The person authorized to receiv� i cr�ema a �a�ed7fbih the crematory is: reo Name: Jlmdk %N.Y.lf2A fwrdtria-►etly4em Weigle Address: j( M 4W CMIIM Phone: The cremated remains of deceased will be disposed of as follows: If for any r/al n t e person Ld above doe no l take puss 4ion the cremated remains, ') 1' t� j, is utho?2pd to give A s ion of the remains to t" (� `e el, �'� JJ y de Tune el Home Na—)in person or by registered mail. ( 1v •��!' Warne of Dexased) DOS-18984(Rev.04120) Page 2 of 3 RX Da-s'Time 05/12/2020 06:42 15164136355 P.001 May 12 20 03:28a Melford C.Everett 15164136355 p.1 Authorization for Cremation and Disposition (lnitia/the following) 1f 9 I/We unde.t$ng[at if th re a4sre not clai ed 'n 120 days of cremation. L I' lr r p � �/�,-� ,�i ( I ,, +�`� �" t" may dispose of the remains in (Nome d Gematnry) an irretrievable manner,such as by scattering. CREMATION CONTAINER/URN (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: 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. X , An um is n1 yet purchase�lMe understand at if no um is purchased or otherwise provided t � I r A � "\k 1) {t will place the cremated remains in y (Name o!G amaforyJ a rigid temporary container for delivery. This Authorization Form was provided by was executed at 1*4 puffic Street (Funeral Home Na My.UZA Web-f! (Funeral None All,"M 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 is/are the person(s)in control of disposition,who by signing this Authorization Form,attest(s) to the accurac n rompleteness V nformation contained in this Authorization Form and authorizes)the foregoing. Sinned this dayofCU4 ,20 ' n A ss Typed or Printed Name Srgnowe Address ryped or Printed Name Signa" Addre (Funeral irarforTypedorPiuved _ (Funeral Directors re) egisrro6on Nu,nDer) (Nano or0e W DOS-1898-f(Rev.04120) Page 3 of 3