Lapidus, Herbert Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: QJ
RETURN TIME:
DATE & TIME REMAINS ARRIVE AT CREMATORY: Z 30
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
NAME: ------ ------_-_ -
TYPE OF CONTAINER:
PLACE OF DEATH:
ESTIMATED WEIGHT OF REMAINS & CONTAINER__.____ ��,Q� � Z`0
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION:
TIME STARTED: /0't(p
-_ TIME COMPLETED: 12
.7
09h PLACED IN RETORT: --
--____--- I�' 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 Y4RK Division of DIVISION OF CEMETERIES
STATE OF One Commerce Plaza
OPPORTUNITY. Cemeteries
99 Washington Avenue
Albany,NY 12231-0001
Telephone:(518)474-6226
www.dos.ny.gov
Authorization for Cremation and Disposition
This Authorization Form must be completed and signed prior to delivery of remains for cremation.
Date: 05/08/2020 Number:
Crematory Name: Pineview Crematory
Address: 21 Quaker Rd, Queensbury, NY 12804 Phone: (518)745-4476
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
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
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 DECEASED
Name of Deceased: Herbert Lapidus Marital Status: Married
Last Known Address: 2514 Eileen Court, North Bellmore, NY, 11710
Place of Death: Nassau , 2201 Hempstead Turnpike, East Meadow, NY, 11554
Sex: ®M 0 F Age: 90 DOB: 07/15/1929 Date of Death: 05/02/2020 Estimated Weight: 190
Description of casket/container in which remains will be delivered.
Alternative Cremation Container
PERSON IN CONTROL OF DISPOSITION
(Person(s)in control of disposition, initial ONE of the following)
` 4 1 am/We are the designated agent of the deceased designated in a will or written instrument executed pursuant to Public
Health Law Section 4201.
-OR-
I/We have no knowledge that the deceased executed a written instrument pursuant to Public Health Law Section 4201 or a
will containing directions for the disposition of his or her remains and I/we are the person(s)having priority under Public Health Law
Section 4201 and have the right to authorize cremation of the remains of the deceased. My/Our relationship to the deceased is as
follows:
Herbert Lapidus
(Name of Deceased)
DOS-1898-f(Rev.04/20) Page 1 of 3
Authorization for Cremation and Disposition
(Insert from the list below)
Number: 3 Description:Adult Son
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;
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).
(Initial ALL THREE 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 radioactive device and that any such materials were removed prior to the execution of this Authorization Form. Failure to remove
these items prior to cremation may result in harm to the crematory and crematory personnel.
e. I/We affirm that instructions have been given to Michael Noll
- (Funeral Director Name)
regarding the removal of any personal property or other thing of value which any person signing below or any family member of the
deceased wishes to preserve. Pineview Crematory 21 Quaker Rd, Queensbury, NY 12804
(Crematory Name)
is not responsible for the removal of personal items from the container or from the remains of the deceased. Personal items left in the
container or with the remains will be destroyed by the cremation process and cannot be retrieved after cremation.
I/We hereby authorize Pineview Crematory 21 Quaker Rd, Queensbury, NY 12804
(Crematory Name)
to cremate the remains of the deceased.
(Initial OPTIONAL)
—44 I/we hereby authorize the named funeral director to provide for delivery to and cremation by an alternate
crematory,if deemed necessary in the opinion of the funeral director,and to amend this form to provide the correct name and
address of such alternate crematory.
FINAL DISPOSITION
The person authorized to receive the cremated remains of the deceased from the crematory is:
Name: Larry Lapidus
Address: 24 E Pierson Ave Somers Point NJ Phone:6096024058
The cremated remains of deceased will be disposed of as foil s:
Burial at Beth Moses CemeteryM I t
If for any reason the person named above does not take possession of the cremated remains,
Pineview Crematory 21 Quaker Rd, Queensbury, NY 12804 is authorized to give possession of
New Leaf Cremation (Crematory Name)
the remains to by delivery
(Funeral Home Name)
in person or by registered mail. Herbert Lapidus
(Name of Deceased)
DOS-1898-f(Rev.04/20) Page 2 of 3
A
Authorization for Cremation and Disposition
(In tial(he following)
L� I/We understand that if the remains are not claimed within 120 days of cremation,
Pineview Crematory 21 Quaker Rd, Queensbury, NY 12804 may dispose of the remains in
(Name of Crematory)
an irretrievable manner, such as by scattering.
CREMATION CONTAINER/URN
(Initial)ONE of the following)
L An urn to be used as a container for the cremated remains has been purchased from New Leaf Cremation
and is described as follows: Large Eco Urn
I/We understand that if the urn is too small to hold the entire cremated remains,an additional rigid container may be used for delivery.
-OR-
`(` h An urn is not yet purchased. I/We understand that if no urn is purchased or otherwise provided
Pineview Crematory 21 Quaker Rd, Queensbury, NY 12804 will place the cremated remains in
(Name of Crematory)
a rigid temporary container for delivery.
Michael Noll
This Authorization Form was provided by was executed at
New Leaf Cremation (Funeral Director Name)
(Funeral Home Name)
3930 Long Beach Rd., Island Park, NY 11558
(Funeral Home Address)
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 accuracy and completeness of the information contained in this Authorization Form and authorize(s)the foregoing.
Signed this 8 day of May 20 2020
Larry Lapidus �Zik
Typed or Printed Name Signature
24 E Pierson Ave Somers Point NJ
Address
Typed or Printed Name Signature
Address
Typed or Printed Name Signature
Address
WITNESS:
Michael Noll
(Funeral Director Typed or Printed Nam (Funeral Director Signature)
(Registration Number)
Herbert Lapidus
(Name of Deceased)
DOS-1898-f(Rev.04/20) Page 3 of 3
PUBLIC HEALTH LAW
§ 4145• Deaths; burial and removal permits; disposition of remains. 1. No person in charge of any premises on which
interments, cremations or other disposition of the body of a deceased person are made shall inter or permit the
interment or other disposition of any body unless it is accompanied by a burial,cremation or transit permit,as provided
in this article.
2. (a) The funeral director or undertaker shall deliver the burial permit to the person in charge of the place of burial or
other disposition before interring or otherwise disposing of the body or shall attach the removal or transit permit to the
box containing the body,when shipped by any transportation company,which permit shall accompany the remains to its
destination, where, if within this state, it shall be delivered to the person in charge of the place of burial or other
disposition.
(b)Any person or other entity owning,operating,managing,or designated to receive the body of a deceased person at a
place of burial, cremation, or other final disposition in this state, who receives the body of a deceased person, shall
provide a receipt for the body to the funeral director, undertaker or registered resident who delivered such body. Each
receipt shall (i) be endorsed by both such person and the funeral director, undertaker or registered resident,(ii) indicate
the date the body was delivered, (iii) include the name of the funeral director, undertaker or registered resident
delivering the body and the registration number of such funeral director, undertaker or registered resident, (iv) include
the name of the registered funeral firm the funeral director,undertaker or registered resident represents,(v) include the
name of the deceased person as it appears on the burial, cremation, or transit permit, and (vi) include the name of the
owner, operator, manager, or person in charge of the place of burial, cremation, or other final disposition who received
the body of the deceased person.A copy of such receipt shall be retained by the owner,operator, manager,or person in
charge of the place of burial, cremation, or other final disposition for a period of not less than four years, and shall be
made available for inspection by the division of cemeteries during normal business hours.The original copy of every such
receipt shall be retained by the licensed funeral firm for a period of not less than four years pursuant to the rules and
regulations of the department governing the maintenance of records.
3.The person in charge of the place of burial or other disposition shall endorse upon the permit,the date of interment,
or cremation or other disposition over his signature, and shall return all permits so endorsed to the registrar of his
district within seven days after the date of interment,cremation or other disposition.
4. When burying or otherwise disposing of the body of a deceased person in a cemetery or burial place having no
person in charge,the funeral director or undertaker shall (a) sign the burial or removal permit,giving the date of burial;
(b) write across the face of the permit the words"No person in charge; " and (c) file the burial or removal permit within
three days with the registrar of the district in which the cemetery is located.
5.The person in charge of the place of burial,cremation,or other disposition shall keep a record of all bodies interred or
otherwise disposed of on the premises under his charge,in each case stating the name of each deceased person,place of
death, date of burial or disposal, and name and address of the funeral director or undertaker,which record shall at all
time be open to official inspection.
DOH-1555(07/18)p 2 of 2