Whalen, Joseph Adrian Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 Or (518) 745-4476
FUNERAL HOME:
_._ RETURN TIME:
DATE A TIME REMAINS ARRIVED AT CREMATORY
NAME OF FUNERAL DIRECTOR OR REGERSTERED RESIDENT DELIVERING R IIL�
EMAINS:
NAME; _TYPE OF OF CONTAINER:
- _CASE p 0
n„IkNd lam._.-5� K. 1 __3exd PLACE OF DegTN:
ESTIMATED WEIGHT OF REMAINS 8 CONTAINER_
PLACED IN HOLD:
PLACED IN REFRIGERATION: ___ '--'---
DATE OF CREMATION:
TIME STARTED: _— b-
-' -TIME COMPLETED: �L:YMIA
PLACED IN RETORT: �� - -''-U—
.. .MOVED: .. __. __.RibPL•,q
RETORT pIN WHICH REMAINS WERE CREMATED: ) —
DETAILED REASON FOR DELAY IF __..._.MORE THAN
HOURS
REMAINS WERE CREMATED MORE THAN q8 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE:THE CREMATION LOc sx -wLl BE RETIRED IN THE pEDMgX[HT FILE OF THE CnEMpiOgY.
Auth?rization for Cremation and Disposition
One remains Plaza.99 zwzPaxzzxxzww
MS Antilwlgati Form pool compleled and signed prior o radial of remains for cremation.
Date: W4110 founall loJ
Crematory Name: Pine Yew Cremalory
Atldrees. Quaker Read, One encoal New Vprk 12804 Initial 518 T45-46]T
CREMATION 15 AN I0.REancia 1E AND FINAL PROCESS.
Cremation Is carried out by placing the remains of the deceased and the container holding the remains into a
cremation chamberwherethey are subhuman to Intense M1emand flame.The heat and Rome will[Mnr and canwme
everything eampt from and metal,which are all that will be NR after minima pn.
Followlin cremation,the crematory will take reasonable efforts to not the re me ins and Other material fmm 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 placetl into a designated container or urn. Overcome
remains gMmlly are"Mxd until no Awe fragment N material as"M dune.
OPENING OF CONTAINER
The crematory may only open the container holding the unaremmed human remains in limited circumstances, such as to
confirm the identify of the deceased or to ensure that no material is enclosed which might injure employees or damage
rmatoryproperta, If human remains are dNlverM Ina FmtalnerwMt is not sukablefararvnadan such Me ceremonialw
metal osket,Me vemMory will requ rental Me remains be cowedImoa suNaNewnuinn beforeNxcepls 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 prlvaq,
with dignity and respect.
IDENTIFICATION OF D-ETC'EASED 11�x 11 ee � yy � II
NameofD mae :d"A FiA fW1 L-A z lg.Yl Mardalstetur final
Lan Known Address1 ALA a. ` or r� � f IYLJ(G.v� pfp
Plain of DeaM:a�l�. �JbAl � (1i 2d 'PI-4 Nk� \a8oC1
sea: 9W OF Al Done of OeaM- CUIQl EstimatedwaioM:
Description of rasket/mntainer in which remains will be delivered:
Corrugated Cardboard Box with Plivermord StarmarkMil 9 3SMS
PERSON IN CONTROL OF DISPOSITION
perna l in Control Of disposition, initial ONE Of the followingl
I am/We are the "signaled agent of the deceased designated in a will or written instrument executed pursuant to Public
Hall law carbon 4201.
OR
I/We have so knowledge that the deceased executed a written instrument pursuant to Public He Law union 4201 or
a w ill containing directions for the disposition Of his or her remains and IContinued and page)
I am/we are me personis) having prlority under Pubic Heath Law saction Clog and have the right to authorize cremation
of the remains of the deceased.MyFour relationship tome de as Is as follow[:
(ImNfl fat he below/
Numbed—XOescnpdon: LJP TG
A person desgnaled in wrtatg parwuard W Public Heath taw section Q01 (3)',
(D The surviving spouse;
2a.The surviving domestic partner;
3. Any survivimg child eighteen years of We or older,
a. A surviving parent
6. A surviving sibling eighteen years of age or oltler',
6. A lawfully appointed guardiaq
1. Any persomm)eighteen "am of age or older entNed to share in the estate arm who islare closest in
relationship to the deceased,
all A duly appointed fiduciary of me estate;
S. A dose Mend or rela0ve who has executed a written statement pursuant to Public Healtl Law§4201(]);
10. A chief fiscal officer of a county or a public administrator appclnted pursuant to me Surogate's Court
Procedure Ad;
10a. Any other Delon who of;sang on behalf of me dec rased and who has executed a wriaen statement pusuanl
W Pubic Health Law§4201TI't
LALLSLAU meEofthef flowmal
,V- W I/We hereby affirm that the body of the deceased does not contain a batery, battery pack, power cell,radioactive
I m plam, or radioactive device and that am such materials were removed prior to the execution of this Authorization Form.
Fallu as to deal mesa Items prior to cremation may result in harm to Me crematory aN crematory persuaded.
SIU) 1/Aehereby affirm that instructions have been given to uvMrmm,,.xvrvvy Coma Rurcdmicam regaMingthe
nermovall Many personal property or other thing of value whIch any person signing below or any family member of the deceased
wishes to preserve. b.ememynmmel Pine Vim Gemaory s not responsible for removal of Personal
items from the container or from the remains of the deceased. Personal Items left In me examined or coat the remalm will be
destroyleedbythe menages process and cannot be retrieved affair increases.
w 1/We hereby auturrize emxvt Firm View Mai t0 mein the remalmOf
Fde ased.
FINAL DISPOSITION
The person authorized W receive Me cremaled remains of Me tlamsetl ham the uemabry as
Name: P
Address: 11 Ufaccuffix Streved, Q abuN, New Year 12804 Phone: (5181 ID1-0303
The cremated remams of decreased!will ba disposed of as fellows:
Realm W family M be derided
R for any reawn the person named above does not take Iloaaession of the cremated remains,
w
(vamemyn.mal P V C W attended W give Ia>asassion of the remains b
lN.rrdmm=�wsl Baker Fun rat Home by delivery In person or by registered mail.
cassarularv.oVwl = 0~ Pei
QpQpirne)onommo)
Al undemMMMMRMeemainsamn daYnaE in 120daysacemation,
lmwrewr�mil Piney Creirml may dispose of she remains in an irretrievebla manner,
such as by scattering.
CREMATION CONTAINERNRN
rIMMa1nNF oflM folloHngf
An u to be used as a mmisomer for the emaleU remains has bean purchased From Baker
Funemlm IX
Home and a described as follows: LdOO 0(W
VAe understand Mat if Me um is Ito small M hold Me entre cremated remains, an additional rgtl container may be used
fordelivery.
OR
____An um has not yet been purchased. INIe understands Ma R no um is purchased or otherwise promed mmm,
nape Pine View CremaMry will place the cremated remains In a rpid temporary
container for delivery.
This Authorization Form was provided by ryw.wwnwmmel Gss'a RaHem M1CIW
was executed at pureminunemmel RaMrFunera Hame
Mam.lrvoma.e:naol 11 Lafavetre Street. Oueensdlrv. New York t2001 eM 'Is sal by Me Funeral dlrecMr
as wllness M its a umbon.
IN.b have rersrved a completed ropy of MIS Authorization Form
The personfs) identified bel issue the parapets) in cpnhof ofaispositiont who by signing this Authorization
Form, affest(s) to the accutacy and comple msess of Me hairmsabuir comansedin Ups ApModze con Form arm
authodzets) the huegning.
signs lMts 3r`� daya 5w.ar m '>o
av AAdmm, .,z (2 ., Q,loor 4, t gQy IV
m xm�
r sm m Arms.
WITNESS: C 1s.hA�F ItaYJ(e —
Cess'a Relfem L
ruvmorvennimaniM¢a xmre rnwmsv Weere
Funeral Home Rea Yo1130
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