Montefalcon, Teresita Plate Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: _-
-----� �MTa4L) RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: j0 flh-
'-
NAME OF FUNERAL DIRECTOR OR REGRIST
ERED RESIDENT DELIVERING REMAINS:
------------- _-
NAME: ✓�W �1t0 --
./�. - - --------CASE # --
TYPE OF CONTAINER: _. ._C _ ---- --
----------------
PLACE OF DEATH: 3S(S f r fnj
--
ESTIMATED WEIGHT OF REMAINS & CONTAINER__.. k36'
PLACED IN HOLD; _-
PLACED IN REFRIGERATION: -
DATE OF CREMATION: $-
TIME STARTED: _ 3/Q � ------------------------- --
--------.-______._.TIME COMPLETED:
PLACED IN RETORT: / y✓� -
-p/p -..-- -----MOVED:
RETORT # IN WHICH REMAINS WERE CREMATED: 7
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.
New Yvrk Stole
Department of state
1"EWYORK Division of P OF CEMETERIES
E OF One Commorce Place
ORTUNITY. Cemeteries 99WaQ*MvnAaenue
Albany.W 12231-t1001
Telephone:(SIM 47"220
www.day-ny.gov
Authorization for Cremation and Disposition
We Authorixadon Form must be completed and mlgned Prior to delivery of remains for cremation,
Date, 05/1112020 Number
Crematory Name:Pineview Crematory
Address:71 Quaker Rd 0ueenabury,NY 12804 Phone: (518)7454476
CREMAWN 19 AN IRREVERSiBLE AND FINAL PROCESS.
Cremation is carried out by plat"the remains of ate deceased and the Container holding the remains into a cremation chamber where
they are subjected to intense heat and flan. she neat and flame w1il Incinerate and consume everything except tame and metal,
which are all that will be left after wwrotion.
Following crernstian,the Crematory will take reasonable efforts to remove all of the remains and other material from tie cremation
chamber,but some minimal dust and residue will likely be left behirid. The crematory will separew incidental and foreign material from
tho mmalm and the incidental and foreign material will be disposed of ae required by law. The cremated remains will be mechanically
pulverized into smelt pieces and pieced Into a designated container or um. Cremated remains generally am pulvertrad Mail no
single,fragment is recognizable as skeletal tissue.
pENIN6 oF Tl E OVAINER
The crematory may only open the container holding the un-cremated human remains In tinkled 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 cemetery property. If
human remains are delivered in a container 1Vhich is not subble for cremadcm such as Ce.oil onial or recital casket,the
crcrnebory wilt require that the retrains be moved Into a suftblo container before It accept*the remains. The opening of a
container or the tranefer or removal of remains will be conducted before a witness and will b4 done in privacy,with dignity and respect.
IDENTIFICATION OF DE9!8
Name of Deceased:_. Teresita Plata Montsfatcon Marital status: Never marred
Last Known Address: 35-15 Persons Blvd.Flushing,NY 11354
PhDs of Death. Sapphire Center For Rehab&Nursing Of Central Queens,3515 Parsons Blvd.,Flushing,NY,11354
Sax: Q M 13 F Age. 79 D08:05=1940 Date of Death: D41O /Y020 Estimated Weight:135
Desalprlon of casket/container lei which remains will be dotivened.
Alternative Cremation Container
PE I CONTROL OSITION
r (s)ih comma of d4wowWan,inttlal ONE of the ngJ
I amlWe are the designated agent of the deceased designated in a will or wrmen instrument w=tded pursuant to Public
Health taw Section 4Z01,
.OR-
�� I/We have no knowledge that the deoeased mmmied a wrlRen instrument pursuant to Public Haellh Law Section 4201 or a
will oontairrng directions for the disposition of his or her remains and Ilwe are the person(s)haAng priority under Public Heetti Law
Section 4201 and have the right to authorize Cremation of the remains of the deceased. Mylour relationship to the deceased if as
follows;
Teresita Plata Montefolcon
fi"�Ur
DOS-1 BOafi(Rev.oarza)
Page 1 of 3
VA d « £9L699L9L5 Ajonliow us looW 90:60 IL-50-OZOZ
Authorization for Cremation and Disposition
(Inwft from the fist befow)
Number, 5 Dewiption•sister _
1. A person designated in writing pursuant to Public Health Law$@coon 4201(3y,
2. The surviving spouse;
2a. The surviving domestic partner,
3. Any surviving child eighteen year*of age or older.
4. A surviving parent:
5. A surviving sibling elghteen years of age or older;
6. A jawfyliy appointed guardian;
7. Any person(s)eighteen years of age or older anulled to share in the estate and who Ware closest in relationship to the deceased;
a. A duty appointed fiduciary of the astete:
9. A dose friend or relative who has executed a written statement pursuant to Public Health Law Section 4201(7):
10. A duet'fiscal offerer of a county or a public administrator appointed pursuant to the Surrogate's Caul Procedure Ad:
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).
fja&)ALL n-fRE-E of ttw foffowfrng)
'7 I/We hereby affirm that the body of the deceased does not contain a battery,bom pack,power cell,radimcfNe implant,
or radioactive devitca and that any such materials were removed prior to the execution of this Authorisation Form. Failure to remove
these Items prior to cra rratlon may result in harm to the Crematory and crematory personnel.
F.P. VWe affirm that instructlons have been given to Michael Noll
reger'ding the removal of any personal property or other ftti v of value which any person aigning buiow or any family member of the
deceased wtShes to preserve. Pinevi"Crematory 21 Quaker Rd,Queensbury,NY 12804
tc-MbrROMO
is not responsible for the remove)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 retrlevad after cremation.
.EP ffWe har9by authorize Pineview,Crematory 21 Quaker Rd,Queansbury.NY 12804
ta.ruro�r a..»�
to cremate the remains of the deceased.
(Mg OP7101VAf_)
Vom hereby authorize the named funeral director to provide for defivery to and cremation by an aPoernate
crematory,If deemed neoessary In the opinion of the funeral cfiwctor,and to amend this form to provide the oorreot name and
address of such alternate crematory.
FINAL DISPOSITION
The person authorized to receive thv cremated remains of the deceased tom the crematory is:
Nerve: EdInde Pascual
Addrems. 431 Beach 20th Street phone;7183272701
The cremated remains of doomed will be disposed of as fol :
If for any reason the person named above does net take possession of the cremated remains,
Pineyierw Crematory 21 Quaker Rd,Queensbury,NY 12804 is authortzed to give possession of
New Leaf Cremation Mm"""NOW)
fate remains to by delivery
(Fer,.earrro�w nae,y
In person or by registered mall. Teresita Plata Montefalcon
fNeeln dOrcest�q!
DOS-1898-f(Rev.04M) Page 2 of 3
C17 d « £91699L%S AjonvoW uajaeW 60:60 h-50-020Z
Authorization for Cremation and Disposition
(t Aki the following)
Me,understand that if the remains are not chimed whin 120 days of cremation,
Pineview Crematory 21 Quaker Rd,Queenabuty,NY 12804
may dispose of the remains in
Pftwufcowftku�9
an Irretrievable manner,such as by scattering,
CRPA T[ON CONTAINER_URN
(n (ONE of the fa kwft)
!/�"Ao An um to be used as a container for the cremated remains has been purchased fromR!
and is described as follows•
I/We understand that if the urn ie too small to hold the entire crarnaied remains,an additional rigid container may be used for de)ivery.
-OR-
An urn is not yet purchased. IIWe understand that If no urn Is purchased of otherwise provided
Pineview Crematory 21 Quaker Rd,Queensbury,NY 12804 will pleme the cremated remains in
iftm of OMsowh
a rigid temporary container for delivery.
tutichael Noll
This Autltarfzatlon Form was provided by was executed at
New Leaf Cremation
3830 Long Beach Rd-,Island Park,NY 11558 �
and Is signed by the funeral director as witness to its execution.
I/We have received a completed copy of this Authorkation Form.
The pereon(s)ider>trf'red below islam the parsons)in ooelKoi of disposition,who by signing this Atrfholhatba Form,atiest(s)
to the accuracy and completeness of the informatrod contained in this Auto nflon Form and autllo &4s)the foregoing.
Signed this 14 day of May ,20 20
Erfiinda Pascual X �
,9rdo.t'iarsa
ear Beech 20th sweet r
4vWdrM9*dNww Wan
Aw"s
rya»cawerea nrew.
.clown
WITNESS:
Michael Noll
Teresita Plata Montefatcon
DO$-lava-r(Rev,04120) Page 3 of 3
s/� d 44 £916991965 AJen4jow uapeN 60:60 � L-50-020Z