Spizzo, Beverly A 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. R W
NAME OF FUNERAL DIRECTOR OR REGRISTEREO RESIDENT DELIVERING REMAINS-
NAME:
p LF �p
y_LZW
TYPE OF CONTAINER: _—CASEN
-- - MINA- - �d 4 <qR>6P
PLACE OF DEATH: S � --
-- -- �Ih_luf h 1u3�
ESTIMATED WEIGHT OF REMAINS S CONTAINER____ Ll(
PLACED IN HOLO: - - _
PLACED IN REFRIGERATION: ___ -
�____
DATE OF CREMATION: - - "—'—
Fie$ 90
TIME STARTED: M-
CL..__.__TIME COMPLETED! � 070/�l
PLACED IN RETORT; =-,i—
'
RETORT N IN WHICH REMAINS WERE CREMATED: g OEM
ink y
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE TNY�gNs HOURSfid
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOGS -Ngll BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
- R
Authorization for Cremation and Disposition pro ,°oo dcemNl�.x
oz UMMiYeleas W W®Mrylm Awnw
AMny NY 12231
(818)474
v,w.di sure.we
This Authorizatlon Fort proxy be completed andsignedprlor to delivery of remains for cremation.
Date'. 5/2W0 Number:
Crematory Name: Pine View Crematorium ((
Address: Quaker Road Queensberry NY 128N Phone: U1g
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation is canned out by plating the remains of the deceased and the container holding the remains into a
cremation chamber wham they are subjected to intense heat and flame. The heat and flame will Incinerate and
consume everything except bons and metal, which are all that will be left after cremation.
Following cremation, the crematory will take reasonable efforts to remove all of the remains and other marshal 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 am pulverized until no single fragment is
recognizable as skeletal Ussue.
OPENING OF CONTAINER.
The crematory may only open the container holding the uncremaled human remains in limited circumstances, such
as to confirm the idenWy of the deceased or to ensure that no material is enclosed which might injure employees or
damage crematory property. If human remains are delivered Ina container which Is not suitable for cremation
such as a uremonlal or rental casket Me crematory will require Nat the remains be moved into a suitable
container before It accepts 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 privacy, with dignity and respect.
IDENTIFICATION OF DECEASED 1
Name of Deceased Beverly A. Sol= Marital Statu Ma
rried
arried
Last Known Address: 5 East LeClair St., Hudson Falls New York 12839
Place of Death: 5 East LaClaire St., Hudson Falls New York 12839
Sex: M O Age: 84 DOB: 10/23/1935 Dateof Death: 0512412020 ESUmated Weght: 151EIK
Deaviptlon of caskeVcontainer In which remains will be delivered: Matthews Cxmation Case- Cardboard top,
Plywood honour
PERSON IN CONTROL OF DISPOSITION
(Persons) in control of disposition, viral ONE of the rollowing)
I am/ We are the designated agent of the daclosed designated in a will or written Instrument executed
punne nt to Public Heath Law section 4201.
-OR-
I/We have rm knowledgedeceased that the executed a written instrument PUMUam to Public Health law
secti n 4201 or a will containing directions for the disposition of his or her remains and (Continued next Pager
Beverly A Spixzo
OOAl"54A lacy.0110) hem cfOxtrwd Pmi1N3
ant we are the Wria n(s) having priority under Public Health Law section 4201 and have the right to authorize
overall on of the remains of the deceased. MylOur relationship to the decummul is asfollows:
(Insert hors the list below)
Number: Deacdption: J�a. J h-fr�
1. A person designated in writing pursuant to Public Health Law section 4201(3);
2. The surviving spouse;
as. The surviving domestic partner;
2. Any surviving child eighteen years of age or older;
4. A surviving parent,
5. A surviving sibling eighteen yeare of age or older:
6. A lawfully appointed guardian',
T. Any persons) eighteen years of age or older entitled to share in the estate and who islare closest in
relationship to the deceased;
8. A duly appointed fiduciary of the estate;
9. A dose Mend or relative who has executed a written statement pursuant to Public Health Law §4201(7);
10. A chief fiscal officer of a county or a public administrator appointed pursuant to the Surrogate's Court
Procedure Act',
10a. Any other parson who is acting on behalf of the deceased and who has executed a written statement
pumi to Public Health Law §42g1(T)
((y(�ALL THREE d the follosest)
uar=[/ IWe hereby affirm that the body of the deceased does not contain a battery, battery pack, power cell,
fiscal implant, or radioactive device and that any such materials were removed prior to the execution of this
Authorization Form. Failure to remove these Items prior to cremation may result in harm to the cromatory and
crematory personnel.
IWe hereby affirm that instructions have been given to pww,wMearwn.m.) Cassandre S. Mvlle
raga ing the removal of any personal property, or other thing of value which any person signing below or any family
memberof the deceased wishes to preserve. rcmmemynamq Pine View Crematorium rent
responsible for removal of personal items from the container or from the remains of the deceased. Femoral items
left In the container or with the remains will that destroyed by the cremation process and cannot be marketed
after cremation.
44 IM* hereby authorize rommamynamel Pine View Crematorium to cremate the
remains of the deceased.
FINAL DISPOSITION
The person aNhor zed to receive Me cremated remains of the deceased from the crematory is:
Name: Carl Funeral Home, Inc.
Address: 68 Main Street, Hudson Falls NY 12839 Phone: 518-7474243
The cremated remains of deceased will be disposed of as tctlows:
If for any reason the person named above does not take possession of the cremated remains,
rc.melmrnemel Pine View Crennal is authorized to give possession of the remains to
m,n.arrmmn nemel Cariemn Feneml Home, Inc. by delivery in person or by registered mail.
Beverly A. Spivs
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(ouga the lelowiry)
IMe understand that tithe remains ere not claimed within f 20 days of cremation,
(we a nxn Pine View Crematorium may dispoal of the remains in an irretrievable manner,
such as by Scattering.
CREMATION CONTAINERNRN
argil l ONE of the lolloweq)
An um to be used as a container for the cremated remains has been Wmhased from
Carleton Funeral Home Inc.. and Is described as follows:
I Wo understand that I the um is too small to hold the entire cremated remains, an additional rigid container may be
usedfordelivery.
OR-
r�� yn,�p An um has not yet been purchased I=e underhand Mat if no um is Wr ased or otherwise provided
(uvn,"m 'y :) Pine View Crematorium will place the cremated remains in a rigid temporary
container for delivery.
The Authorization Form was provided by ((. oa mina Cassandra S. Mulls
was executed at (manmdm„one) Carl Fuel Home Inc.
Ihmemi hmw Wiwi) 68 Main Street Hudson Falls NY 12839 and is signed by the funarel director
as witness to its execution.
IWe have received a completed copy of this Authorization Foos.
The persontsl identified below Islare the personts) In control of disposition, who by signing this
Authorization Form, sheave) to the accuracy and completeness of the Information contained in this
Authorization Form and authorizets)the foregoing.
Signed this 26 day of Me , M 200 .
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Address
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Address
WITNESS:
Cassandra S. Maine
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Beverly A Spizzo
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