Ellithorpe, James Owen Fine View Cemetery a Crematorium
Quaker Road
Queensburyl NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME; _ Aft IL
..._.. ._.._ RETURN TIME. NL"E
BATE g TIME REMAINS ARRIVED AT CREMATORY LL
NAME OF FUNERAL DIRECTOR
�O RR�REGRIISVTERED RESIDENT DELIVERING REMAIN
NAME
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TYPE OF CONTAINEq LII —CASE p 488�
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PLACE OF OEATX: . .
ESTIMATED WEIGHT OF --�"--�-REMAINS 8 CONTAINER
PLACED IN HOLD:
PIgCIO IN REFRIGERATION: ___ — 11-- --�
DATE OF CREMATION: {Na1
ZD
TIME
PLACED IN RETORT:
TIME COMPLETED:
PLACED IN RETOgT: � n I Ip�._.__,:JGDIT .____MOVED:
RETORTp IN WHICH REMAINS WERE LCREMATED: _ ._ f � I
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED OELIVERYI
NOTE:THE CREMATION wo SHA
LL RE RETAINED IH THE PERMANENT FILE OF THE CnEmgiOgY.
Authorization for Cremation and Disposition
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This Auasoaaaaon Form mu#be complafatla sVneapdor M Caiividi r Mns rorcmnaaon.
Data SIt?jw Number �$$
Cmmmt Name'. Pine V Crematary
Addreed Quaker Road Oueensbury, New York 128114 Phone: 518)]45-0477
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
transition chamber wherethey are subjected to intense heat and flame.The heal and flame will Indictment and comments
everything except bone and metal,which are all that will be left after cremation.
Following cre rare n, Ihe crematory will take reasonable eff prod t n of the came iIs and other mate no from the
orematio chamber, but some minimal dust and residue At If Igay,be left behind The crematory wlII separate Incidents ant
foreign material from the remains and the Incidental and foreign material will be disposed of as required by low. The
cremated remains will be mechanically pulverized Into small pieces and placed Into a designated container or urn. Cmma d
remains gen rally are pulverized will no dnght hgdmddA Is rtmgnlzaWe As MSlmal InitialOPENING OF 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 the no material is enclosed which might injure employees or damage
crematory property. If human remenM are delivered Ina container whkh Is ram suitable for cremalon such al ceremonial or
rental uskeq the crematory will requlre that the remains be moved Into a suitable container belwe it=a the remains.The
opening of a container or the transfer or removal of remains will be conducted before a witness and All be done in privacy,
with dignity and infuser
IDENTIFICATION OF DECEASED
Name of Deoeasea'. `79n OrodLD 66c -rhW Par' Marmismtudc v, /
Last Known Address: Q J I 2
Place [M Death: /!/ UC Jt/_
Se.: AIVI DF Age DOE: /d /l J Lf DateWDeets: ,S� 13 yp Estimated Waight / 7r�
Description of casket/container in which remains will be delivered!
Corrugated with Plywood Standard Mod d 3
PERSON IN CONTROL OF DISPOSITION
(Persons)in comml of disposition, initial ONE of the Following)
I ant We are the designated agent of the deceased designated in a will or written instrument executed pursuant to Public
Health law section 4201.
-OR-
Al I/We have no knowledge that the deceased execute ! a written Instrument pursuant to Public Health law section=1 or
will containing dimcb0ns for the disposition of his or her remains and(Continued nest page)
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I am/we are the peron el having priority under Pubic Health law section 4201 and have the right to authorise cremation
Mthe remainsothe deceased.My/sgnelationship to Me Cesu kas blizzoo
(Insertjrom the far below)
Number—9—Igescnpdon'.
A person designated in wdeng pursued m Public Health taw sedron 4201 (3):
QThe surviving spouse;
2a. The survrving domeslic partner.
3. Any surviving child eighteen years d age or older;
4. A surviving parenh
S A surviving sibling eighteen years of age or older',
6. A lawbny appointed guadian;
T. Any persons) eighteen years of age or older entitled M share in the estate and who !dare closest in
relationship to the deceased
g. A duly appointed Fiduciary of the esmde:
g. A close friend or relative who has executed a wMten statement pursuant ro Public Hall Law §4201(7);
10. A chief 05cal officer d a county or a public administrator appointed pursuant M Me Sunogate's Court
Procedure Act.
1 )iu Any other person who is acting on behalf of the deceased and who has executed a written responded pursued
b Public Health Lea§4201(7),
li g lAfLTHREEt/thejollowinpf
RAC I/we hereby affirm the the body of the deceased don natwdna a battery, battery pack power cell, radioactive
implant, or radioactive device and that any such materials were removal prior to the execution or this Approximate Form.
Failure to remove these items press W cremation may result In ham to Me memttery and summary perspnnN.
(we hereby affirm that instructions have been given to µ.rww..ewneml mssoRaHemalafdp regading the
removal of any personal property or other thing of value which any person signing below or any family member of the deceased
wishesto preserve. loon Tev I) Pine View Crematory is not responsible for removal of personal
hems from the container or from the remains of the deceased. personal Items lenm Me Forstmann or with Me remains will be
destroyed by the serration prows and cannot he rearevN Ahern tamer.
fllls I/We hereby authorize on.,orn to castrate the remains of
the deceasetl.
FIHAFplsyoslTlpn
The person authorized to receive the cremated remains of the deceased from Me crematory a
Name: Beer portion HQM
Address 11 Lfa 2004 Phone: (510761A30a
The cremated remains of deceased will be dispose] INaa follcwa:
Rehm to family to be decided
If for any reason are person named above does not take pose on of lore aremde0 remains.
(ovmmyneire) C is authorized m give possession of Me remeiro to
Qmnwhmmenul Bayer Funea Hom by delivery in person or by registered mail.
wsaasafo law.cilia) �"i..�.w e+..2 IF
.&MbardeAt ingi
Asis" IMk understand that tithe remains are rapt claimed within 120 days of cremation,
w.m.rwn mg one view Cremetpry may disposes of the remains in an inadmissible manner,
such as by scattering.
CREMATION CONTAINERNRN
irnitrrl ONE o)Me/olbwinil
An urn to be used as a container for the cremated remains has been permanent from Baker
Funeral Home and is described as folbvrrs
IAefa understand Mat it the um is too small to hold the entire cremated remains, an addi0pnal rigid container may be used
fordelivery.
OR.
An urn has not yet been purchased VAR understand Mat h no urn is purchased or otherwise provided rmmaw
wml F'neU eremaMry will place the uemated remains In a rigid temporary
container Fir delivery.
This Authorization Form was provided by av norr,.adw.el
was executed xµi,.�mno.. l k
rwremminw,aa.=y t NaxY and is signed by the funeral director
as witness to he execution.
INJa have received a completed copy of this Authommon Form.
The persori identrikel halo,dome Me parsons) M comfort of mrsposRion, who by signing this Aulltorrzatlon
Form, attests) to Me accuracy and completeness of Me information contained in Mrs Authorization Form and
authibize(s) the Imegoing.
salthe 7i�04� date!
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