O'Dell, Laurie Ann Pine View Cemetery & Crematorium
Quaker Road
Queensburyl NY 12804
(516) 745-4477 or (515) 745-4476
FUNERAL HOME: _ qq � C1�
RETURN TIME:
OgTEB TIME REMAINS ARRIVED AT CREMATORY' T ]y1 3��
NAME OF FUNERAL DIRECTOR OR REGRISTEREO RESIDENT DELIVERING �
/ REMAINS:
NAME:
-- .__CASE p
TYPE OF CONTAINER: _IL
PLACE OF DEATH: 42 nPd ARN__-..QOS_.�,.�iMJ�ly._L�. NyJ/
ESTIMATED WEIGHT OF REMAINS A CONTAINER__ r F.LA9CF
PLACED IN HOLD: I� "-
__-_.-_---3 __--__
PLACED IN REFRIGERATION: _
DATE OF CREMATION: SJ _
TIME STARTED:
PLACED IN RETORT:
4E ]$^
.
RETORT 4 IN WHICH REMAINS WERE CREMATED:
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 4S HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE:THE CREMATION LOG SHALL BE RETAIMEB :N THE PERMANENT FILE OF THE CREMATORY.
,
-Authorization for Cremation and Disposition t,.ce.wwiti
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Tlrla AUMorl m Form must Oecomplki and signedprim In Miami of rsms/ns for crmraaoe.
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Crematory Name: Pine Yew Crematory
ALdrese: Quaker Ro , Quaanebury, New York 12804 Phone: Blelatz44TI
CREMAnO 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 ahamberwhere they are subjected to intense heat andflame.That beat and flame will incinerate add cmuume
Mrythlry vx bwre and metal,which are all that will be left after mmadbn.
Following crema[On, the formulary will take reasonable eXortstO re move anot in a remains antl other mate naI from the
cremation chamber, but some minimal dust and residue will likely be left beend. 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
crennated remains will be mechanically pulverized into small pieces and placed into a designated container or urn. Crem
mains generally am pulvMaed ul no Bride fmgmem Is ref inure as"tl tissue.
OPENING OF CONTAINER
The crematory, may only open the container holding the aftereffect 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
crematory propeM. If human remains are deity d In a cmRalner watch is not sulbble Mr cm anon such as a ceremonial or
rental us ,the menatory will require that the remains be moved into a subable mrealner belme a aaeets tee femaim. The
Opening of a container or the transfer or removal of remains will be conducted before a whness and will be done In privacy,
with dignity and respect
IDENTIFICATION OF DECEASED y� T�
Nameof Deceased: UTAA"IC (61 O9)!11 Marital Slatln:Az6,red
Last known Address' /� �,
Place of Dei In `t1ju 6eb��u ao
Sex: DM Ilk age:_UL Doe: 6 DammeZam: rX l ,,.lmm� Emimatad igm: /36
Description of czske(/mnfainer in which remains will be delivered �Wa�l�
Corrugated C db d Box with Plywood Southmark Model a 38808
PERSON IN CONTROL OF DISPOSITION
(Per50n(s)in cDlttml of disposition, fa l ONE of the following)
I am/We are ate designated agent of the deceased designated In a will or written Instrument Executed pursuant to Public
Health Law section 4201.
DR
have Iw knowledge that the deceased executed a written instrument pursuant to Public Health law section QO1 Or
a IIImnGiningdirections for the dispostion of his of her remains and (Continued nest page)
�l�-i per chathe
4 I am/we are the person(sl having priority under Public Health Law section 4201 and have the right t0 authwlu promotion
Of the remains of the deceased.laidi mittlmNlp to the disposed Is as fOM'n:
(Inert Me ett mcow)
Number t Oescdption Spint l 1Q v n Rr,�
A person m designated In wrong puuarrt to P IN tow section 4201 (3)',
A Thasurvivingspouse;
L.The surviving domestic partner,
Any surviving chid eighteen yearn of age or older:
A sumnang parent:
S, A surviving sibling eighteen years of age or older;
6. A lawfully appointed guadian:
T. Any pemon(s) eigtdeenyearsofage proiderentNedlosham inthe estate andwho islareclosestin
relafionship to Me deceased;
B. A duly appointed fiduciary of Me estate,
o. Acbseln ormia0 whohasexec awd nsWementpumuantMPublic HealMLaw§4201(]);
10. A chief fiscal officer ofa county or a public administrator appointed pursuant to the Sumogale's Court
Procedure Aol:
1(i Any Other person who is acting on behalf Of 1L¢deceased and who has "x uN a written atatameM pursuant
10 Public Health Law§4201(]).
rrnifialALL THREE of thescuovang)
I/We hereby affimr that the body of the decreased does not contain a Wttery,battery pack, power cell, radioactive
plant, or radiuzctwa device and that any such materials were removed prior to the execution of this Authorization Form.
Fa as rem"Mew Rem Odorto oemetbn may resuh In harm W the customary and cremaory persamul.
I/We hereby off irmthat Instructions have been given to punmwde wTH Corso Raft=A14100 refunding the
now
val of any personal property or other thing of value which any person signing below or any family member of the deteased
r lShes lO preserve. Iwm+Mmmd Pine Vlew(Pemamry is not responsible for removal Of personal
Items from the container Or from Me remains of the deceased. PermrW hems left in the aOMaNwr or wXM1 this remalm will he
?d,icehasi
cr alon Prows and canna he revleved after uematlon.
hereby arments wrvMmmer Pine view crematory to Mar Me remalua
SPOSITION
The person aulhorized to receive the computed! remains Of Me deceased ham the crematory is:
Nam Baker loneral Home Perfacromel
Address: S O N Y rk 128"Y A 128" phorre VIVO761-g303
The cremated margins of designed will be disposed of ea follows'.
Return to family To be decNed
If for any reason the person named above does not fake possewmn ofMe aboard! remains,
memoriam l P Y C fo is authorlaed to give possession of Me hemains0
IwRwv,,nm.,e1 Baker Funeral Home by der ry in person or by registered nl9L
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I:understand Mat If the remains are not Geinrad wahin 120 days W promotion,
t wmrl Pirre View Cremarory may dispose of the remains in an ineldevabs manner,
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h as by spdeang.
CREMATION CONTAINERA/RN
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An um W W used as a container be Me cremated remains has been purchased from Baker
Funeral Home and is peahen! as policies:
INYe understand that gihe um is ton smell to hi Me snore cremated reasons, an saturated rigid container may be used
for survey
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An um has net yet been purchased!. buys understand Mat if no um is purchased or otherwise provided nw,wrw
r Pine View Cramatpry will place Me cremated remains in a rigid temporary
container ror delivery.
firms Authorization Form was provided by(Iimel pas:allafkrNalalW
was executed a[ov.nw M writ Baker Funeral Home
Aumnrrmmemrew 11 Latevatte SVeet Oueensbury New YOM 128d0 end is signed by the Nneral director
as witness b ifs executlrn.
Inver have received a completed copy of the AUMor¢aodn Farm.
The pemon(s) idembfivi below isfave the persons) in cord of disevishion, who by signing this Authorization
Form, attesms) to the accuracy oral wlnpletelreas athe rokermathent contained in Mis Aufhomwyv n From and
auMorlsi to homagatg.
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WITNESS: I,faA afle n�n.al_
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