Corney, Richard W. Pine View Cemetery & Crematorium
Quaker Road
Queensburyl NY 12604
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: _ Ai N£SEJ RETURN TIME:
L� juavk
DATE 8 TIME REMAINS ARRIVED AT CREMATORY: V I/C lµ /o"Pg�M
NAME OF FUNERAL DIRECTOR OR REGR13TERED RESIDENT DELIVERING REMAINS:
PAD/ N
NAME: R CIE CASs R l44
TYPE OF
F CONTAINER
PLACE OF DEATH: 4&f MIIS aP11E '
ESTIMATED WEIGHT OF REMAINS & CONTAINER ILf )M
PLACED IN HOLD: /O:IfA'M
PLACED IN REFRIGERATION: „ICI
DATE OF CREMATION: 170
TIME STARTED: II*ICAYI TIME COMPLETED: IwtPH
PLACED IN RETORT: I6'MAH MOVED: IZVM, i-vorl_F
RETORT S IN WHICH REMAINS WERE CREMATED: j3 f4 0gr
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG RNLLL HE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
g O'Nowenle Sea,
Authorization for Cremation and Disposition NYp..en N barreere.
One Commmm From se m3hrelon Avenue
Abi NY 12231
(51a1
.ew.ma.sw.nY.m
The AU or Won Form must"completed and efgnedpdorto dellvsry of remains forcramadon.
Date: 06/17/2020 Number 7qq
Crematory Name: Pine View Crematorium
Address: Quaker RNad Queenlarav,NY 128N Phone: —
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation is camed out by placing the remains of the deceased and the container holding the remains into a
cremation chamber where they are subjectetl to intense heel and flame. The heat and flame will incinerate and
consume everything except bone and metal, which am all that will be IM after cremation.
Following cremation, the crematory will take reasonable eRprts 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 be disposed of as
required by law. The cremated remains will be mechanically pulverized into small fdeces and placini into a
designated container or um', Cremated remains generally are pulverized until no single fragment is
recognizable as skeletal tissue.
OPENING OF CONTAINER.
The crematory may only open the container holding the un-cremated human remains in limited Ciramstances, such
as to confine the identify of the tleceasetl or to ensure that 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 rental casket the crematory will require that the emalm 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
Name of Deceased Richard W. Corley Marital Status: Mami
Last Known Address: IIOS mSt., Apt5C, GlcmFgls, NY12801
Plaw off Death. Glens Falls Hospatef, 100 Park St., Glens Falls NY 12801
Sex'1 M 1 F Age: 87 DOB' 1111 3/19 3 2 Date of Death: 6/17=0 Estimated Weight: 16511is
Description of casket/container in which remains will be delivered: NtatWeansCrelnationCase -
Car Wb top/plywood bottom _
PERSON IN CONTROL OF DISPOSITION
(Paraon(af in coned Ofdoxedgon. .ome1 ONE of Me examoung)
I am/We are the designated agent of the deceased designated in a will or written instrument executed
pursuant to Public Health Law section 4201.
-OR-
Irvine have no knowledge that the tleceasetl executed a written instrument pursuant to Public Health Law
global 4201 or a wilt containing directions for the disposition of his or her remains and (Construed next pays)
Richard W. Comev
ooslaswl mar oulo) Nai aoeeeeme Page 1 03
I aMvaa are the person(s) having poorly under Public Health Law section 4201 and have the right to authorize
cremation of the remains of the deceased. My/Our relationship to the deceased is as follows:
ilwwr M1wn tore list below)
Number 3 Description. daughter
1. A person designated in wring pursuant to Public Health Law archon 4201(3);
2. The surviving spouse,
2a. The surviving domestic partner;
3. Any surviving child eighteen years of age or alder,
4. A surviving parent;
6. A surviving sibling eighteen years of age or older,
6. A lawfully appointed guardian;
T. Any parsons) eighteen years of age or older entitled to share in the estate and who iWare closest in
relationship to the deceased;
8. A duly appointed fdudary of the estate;
9. A close friend or relative who has executed a written statement pumuant 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 person who is ailing on behalf of the deceased and who has executed a written statement
pursuant to Public Health Law §4201(7)
Qgad ALL THREE of the lollow ns r)
IIWe hereby affirm that me body of the deceased does not contain a battery, battery 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 hems prior to orientation may result in ham to tie crematory and
crematory personnel.
t love hereby affum that instructions have been given to tlaa.,armncrw name Cassandra S. Maille
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 rmmamynaml Pine View Crematorium is
not
for removal of personal items from the container or from the remains of the deceased. Paraonal Mine
left in the container or with the remains will be destroyed by the cremation process and cannot be retrieved
after cremation.
gL Meet hereby authorize rwmekry comet Pine View Crematorium to cremate the
remains of the deceased.
FINAL DISPOSITION
The person authorized to receive 81e cremated remains of the deceased from the crematory is:
Name. Carleton Formal Home Inc
Address: 68 Main Street, Hudson Falls NY 12839 Phone: 5184414243
The cemated remains of deceased will he disposed of as follows:
Returned to family
If for any reason the person named some does not take possession of the cremated remains,
la.meroonemw Pine View Crematory is authorzed to give possession of the remains to
«went come nama) Carleton Funeral Home, Inc. by delivery in person or by registered mail.
Pitched W. Comey
000-1090X1 rear.Orion Name dCewewE Pagan d3
pmsel dM rolrovnnp)
X � A4b understand that if the remains ere not claimed within 120 days of demotion,
finemm.ro.mq Pine View Crematorium may dispose of the remains in an irretrievable manner,
such as by scattering.
CREMATION CONTAINERIURN
(Ling ONE of the/ollowing)
An urn to be used as a container for the cremated remains has been purchased from
Carleton Funeral Home Inc.. and is described as follows:
lMe understand that if the um is too small to hold the entire cremated remains, an additional rigid container may be
used for delivery.
-OR-
Ik _ An urn has not yet been purchased. lMe understand that if no um is purchased or otherwise provided
gwwoe,,w,,n) Pine View Crematorium will place the cremated remains in a rigid temporary
con ainer for delivery.
The Authorization Form was provided by ram,e ae.-e>,amel Cassandra S. Maille
was executed at oxwohm,.m, ej Carleton Funcml Home Inc.
nurcei acme em,mq 68 Main Street Hudson Falls, NY 12839 and is signed by me funeral director
as witness to its execution.
lMe have received a completed copy of this Authorization Form.
The personts) Identi0ed below istam the patients) in control of disposition, who by signing this
Authorization Form, attest(s)W the accuracy and completeness of the information contained in this
Authorization Form and Guth rrize(s) the foregoing.
Signed this 17 day of June , 20 20 .
C"cl
*wmt.e sNF.m.
63 SlyPnl Rd Fort ANY 12827
Acci
Trfaeor F,lMM & sere"
Addasa
TypOw Prew vm 54wa.
Address
WITNESS:
Csssandm S. Maille a �l
Fmme,oAxMTypgm0.MlMMnw ru,emoxw,m sq,ww.
14257
regun nam,mar
Richard W. Cone
000lesau(Res'.mnot Nemeapweese eeaeaaa