Burns, Mary Jane Pine View Cemetery 8 Crematorium
Quaker Road
Queensburyl NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME:
RETURN TIME: ___
DATE 8 TIME REMAINS ARRIVED AT CREMATORY:
11 NAME OF FUNERAL DIRECTOR OR RCGRISTERED RESIDENT OEL'VEAWG
REMAINS-
ME: _.,
-CASE IT
TYAEOF CONT41NER --
PLACE OF DFATH:
------INER ESTIMATED WEIGHT OF REMAINS -�"----
B CONTAINER ___ )Itp f1Iy
PLACED IN HOLD: _ - -- "r '
PLACED IN REFRIGERATION.
OgTF OF CREMATION: "---
__
TIME STARTED: - --
I"XJPO'ME COMPLETED: -
PLACED 1N RETORT:
�- - MOVED: -_
RETORT IN WHICH REMAINS WERE CREMATED: ,-
DETAILED REASON FOR DELAY IF REMAINS WERE CR_EMATEDL MORE THAN A8 HOURS D�
FROM TIME OF ACCEPTED DELIVERY:
NOTE
I THE CREMATION LOG IOTALL BE RETAINEO iN THE FERMAIMNT FILE OF THE CREMATORY.
Authorization for Cremation and Disposition "ron w�of C
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This Attlm eon Form must be camplNW antl srgnedpMrfo clause rY eyremamy cremadon.
Date: 06/04/2020 Number 70%
Crematory Name: Pine View Crematorium
Address: Quaker Road, Queersbury NY 128M Phone: * 716-frY)
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation is canned 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 inCinem% antl
consume everything except bone and metal, which are all Nat will be haft 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 he 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 puNerlsed until no single fragment is
recogniaaMe as small tissue.
OPENING OF CONTAINER.
The crematory may only open the container holding the un-cremated human remains in limited dreumstances, such
as to confirm the identity of the deceased Or to ensure Mat no material is enclosed which might injure employees or
damage crematory property. If human remains are delivered in a container which is not suitable for cremation
such as a ceremonial or renal 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 or remains will be
conducted before a witness and will be done in privacy, with dignity and respell.
IDENTIFICATION OF DECEASED
Name of Deceased: Nfiny Jane Bums Maral Status: Monied
Lan Known Address 12 Lincoln Ave., Glens Falls New York 12801
Place of Death: 12 Li In Sbeet, Modern Falls,Now York 12839
Sex. M (2) Age: 66 DOB: 09/11/1953 DateofDeath: 06/OM020 Eadmated Weght: 141111t;S
Description of casketlmntairsr in which remains will he delivered. Mathews Combat Case
Cardboard top,Plywood bottom
PERSON IN CONTROL OF DISPOSITION
(Personfs)M wntml ofdispovden, inlaell ONE offhe bllowmg)
I am/We are the designated agent of the deceased designated In a will or written Instrument executed
purswnt t0 Public Health Law section 4201.
. IAele have no knowledge that the deceased executed a written instrument pursuant to Public Heats Law
section 4201 or a will containing directions for the dispositon of his or her remains and (LmenueC rexrpage)
Mary Jane Bums
o Ntli t+lee+.olila NvrV wwnaud red,t a
I ant we are the parsons) having poetry under Public Health Law section 4201 and have the right to authorize
crema8on of the remains of the di cessed. MylOur relationship W the decessad Is as folfo ;
(Irlsod from the lid Maker)
Number: 2 Description: Husband
1. A person designated in writing pursuant to Public Heats Law reaction 4201(3)',
2. The surviving spouse;
2a. The surviving domestic banner',
0. Any surviving child eighteen years of age or older;
4. A surviving parent;
S. A surviving sibling eighteen years of age or older;
6. A lawfully appointed guardian,
]. Any person(s) eighteen years of age or older entitled to share in the estate and who islare closest in
relationship to the deceased;
0. A duly appointed fiduciary of the estate,
9. A close Mend or relative who has executed a eight statement pursuant to Public Health Law §421
10. A chief fiscal officer of a county or a public administrator appointed pursuant to the Surrogate's Court
Procedure Act;
tOa. Any other person Me is acing on behalf of the tleceased and who has executed a writlen statement
pursuant to Public Health Law §42O1(7)
1 ALL THREE of the Viewing)
lMe hereby affirm that the body of the deceased does not contain a baftery, hattery 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 poor to cmmation may result in hams to the crematory and
crematory personnel.
Wde hereby affirm that instructions have been given to pure xa.+na-,,.mq Paul M. Dietrich
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. wrmef t,renal Pine View Crematorium 'a not
responsible for removal of personal items from the container orfrom the remains of the deceased. Personal Items
left in the container or with the remains will be destroyed! by the cramatlon process and cannot be rehfor ed
after cremation.
AlarIIWe hereby authooze Pine View Crematorium to cremate the
remains of the deceased.
FINAL DISPOSITION
The person authorized to receive the cremated remains of the deceased from the crematory is:
Name: Carleton Fweral Home, Inc.
Address: 68 Main Street Hudson Falls N 12839 Phone: 518-7474243
The cremated remains of deceased Wit be disposed of as follows:
Su A' A.4 /�e Gage ('e
If for any reason the bacon nametl above does not take possession of the cremated remains,
la.mrron�mOl Piro View Crematory is authorized to give possession of the remains to
@n.reluw�„vmq Carleton Treated Home. Inc. by delivery in person or by registered mail.
Mary Jane Bum
oosteae4+trw.olncl w.mr wo.oa a 70902 as
(mleal the mowing)
IANe understand that I the remains are not claimed within 120 days of cremation,
(mAMIM'" p Pine View Crematonum may dispose of the remains in an irretrievable manner,
such as by sraMaring.
CREMATION CONTAINERNRN
(Ligon ONEOI the fo own ig)
An urn to be used as a container for the cremated remains has been purchased from
Carleton Fur a al Home Inc.. and Is described as follows'.
IANe understand that if the um is too small to hold the entire cremated remains, an additional rgid container may be
used for delivery.
An um has not yst been purchased lMe understand that if no um is purchased or otherwise provided
(o.numv„en,ol Pine View Crematorium will place the cremated remains in a rigid temporery
container for tlelivery.
The Authorization Form was provided by fmmmm.oerwe l Paul M. Dietrich
was executed at du+ws'earmi mraw Carleton Funeral Home Inc.
ImMmi roma wamsi 68 Main Street Hudson Falls NY 12839 and is signed by the funeral director
as witness to Its execution.
IANe have received a completed copy of this Authorization Form.
The persons) Identified below Islam line pereon(s) in control of disposition, who by signing this
Authorization Form, afteads) to the accuracy and completeness of the information contained in this
Authorization Form and authodze(s) the foregoing.
Signed hia '" day of June 20 20 .
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Address;
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PaulM.WITNESS: 64X Jam.
Paul M. Dietrich V�
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10946
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Mary Jose Some
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