Fish, Gloria Annette Pine View Cemetery & Crematorium
Quaker Road
Queensburyl NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: 4CF6FEJ RETURN TIME:
DATE 6 TIME REMAINS ARRIVED AT CREMATORY: . 711 I to I�IaPFI
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
PAU Q_jLj9Vq
NAME: Floo f su CASE R -789
TYPE OF CONTAINER: /17? 1�cd I l T /IL�l ��
7 P.ERp1A PLACE OF DEATH: ID1 �NF EMN 141 Illct'Y 1
ESTIMATED WEIGHT OF REMAINS S CONTAINER 3SO lyI he1y
PLACED IN HOLD:
PLACED IN REFRIGERATION: I'm rYf
DATE OF CREMATION: 7 3-AgZo '^$b
TIME STARTED: _z4 TIME COM�P/LJETED:q
11
PLACED IN RETORT: 7"IF— MOVED: 6 /
RETORT # IN WHICH REMAINS WERE CREMATED: 5. fkr
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORS THAN AS HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SHALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
Authorization for Cremation and Disposition "roeamumae�»a
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This Aurhorizadon Form minutes compildands/grredpdor 0 dallvery of nmther; for cn 80*n.
Date, 6/30R020 Number'. is?
Crematory Name: Pine View Crematorium
Address! Quaker Road, Queensbury,NY 128N Phone:
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation is caned out by placing the remains of the deceased and the container holding the remains into a
cre rmlon chamber where they are subjected to Intense heal and flame. The heat and flame will industrial and
consume everything except bona and mall, 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 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
requiretl by law. The cremated remains will be mechanically pulverized into small pieces and placed into a
designated container or urn; Cremated remains generally are pulverized until no single fragment is
Recognizable as skeletal tissue.
OPENING OF CONTAINER.
The cremal" may only open the container holding tee un.cremated human remains in limited circumstances, such
as to confirm the identity of the deceased or to ensure that no material is enclosed which might injure employees or
damage crematory property. If human remains are delivered in a computer which Is not suitable for cremation
such as a ceremonial or remsl 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 of remains will be
conducted before a witness and will be done in privacy, with dignity and reslced.
IDENTIFICATION OF DECEASED
Name of Deceased Gloria Annette Fish Marital Status: Widowed
Last Known Address: 109 Reynolds Rd Fort Edward New York 12828
Place of Ditayth: 107 Reynolds Rd Fort Edward New York 12828
Sax: M / F 1 Age: 80 DOB: 06/25/1936 Dete of Death: IM29I2O20 Estimated Might &Kiblips
Description o caskeVcontamer in which remains will be delivered: Matthews Cremation Case
Cardboard top, plywood bottom
PERSON IN CONTROL OF DISPOSITION
(Pwson(s)in mnlnv of dispositi em el ONE of the hollowing)
I aml We are the designated agent of the deceased designated In a will or written Instrument executed
pursuant to Public Health Law section 4201.
-OR-
L1We have no knowledge that the deceased executed a written instrument pursuant to Public Health Law
ain 4201 or a will containing directions for the disposition of his or her remains and (cannnu>d nevtpars)
Gloria Annete Fish
ooS.iae&r.l(Rev.01110) AWne NOsuaW pap a
I any we are the persons) having priority under Pudic Health Law section 4201 and have the night to authorize
cremation of the remains of the decaased. Oil relationship to the deceased Was follows:
(Insect Born the list below)
Number: 3 Desorption: Daughter
1. A person designated in writing pursuant to Public Health Law section 4201(3):
2. The surviving spouse;
2a. The surviving domestic partner,
3. Any surviving child eighteen years of age or older;
4. A surviving parent;
B. A surviving sibling eighteen years of age or older
B. A lawfully appointed guarder,
T. Any perennial eighteen yeas of age or older entitled to share in the estate and who is/are closest in
relationship to the deceased,
B. A duly appointed fiduciary of the estate;
9. A close 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,
10s. Any other person who is acting on behalf of the deceased and who has executed a written statement
pursuant to Public Health Law §4201(7)
(Ini=al ALL THREE of the following)
�t _ IMe hereby aHum that the 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 items prior to cremation may result in harm to the crematory and
crematory personnel.
kl� lMe hereby affirm that ins0uctions have been given to rivrawdmea m,vi Cassandra S. Matte
regarding the removal of any personal property or other thing of value which any person signing below or any fatuity
member of the deceased wishes to preserve. Enim i rname) Pine View Crematorium is not
responsible for removal of personal items from the container or from the remains of the deceased. Personal items
left in the container or with the remains will be destroyed by the transition process and cannot be retrieved
after promotion.
Aromalns nm l lMe hereby authorize (murain Pine View Crematorium to cremate the
of the deceased.
FINAL DISPOSITION
The person authadzetl to receive the crammed remains of the deceased from the crematory is:
Name'. Cohan Funeral Home Inc.
Address: 68 Main Street Hudson Falls,NY 12839 Phone: 519-7474243
The cremated remains of deceased will be disposed of as follows:
faturn to Whop
If for any reason the peson named above does not take possession either cremated remains,
(oemsmym"rj Pine View Crematory is authorial to give possession of the remains to
pmee,xmme n ma Carleton Formal Home, Inc, by delivery in person or by registered mail.
Gloria Annette Fish
ooSle9ari law.nine) Nemecoexi Fpama
(todjal the (dbwii
lMe understand Mat 8 the remains are not claimed within 120 days of cremation,
lcwnslm nemn Pine View Crematorium may dispose of the remains in an irretrievable manner,
such as by scattering.
CREMATION CONTAINERIIIRN
(Idfiel ONE of the knowing)
An um to be used as a container for the cremated remains has been purchased from
Carleton Funeral Home Inc.. and is described as follows:
WOe understand that if 81e um is too small to hold the entire cremated remains, an additional rigid cornalner may be
used for delivery.
-OR-
0 An um has not yet been purchased. Me understand that if no urn is purchased or otherwise provided
rM,VW vm) Pine View Crematorium will place the cremated remains in a rigid temporary
container for delivery.
The Authorization Form was provided by ra.ayeaedwn.,n) Cassandra S. Maille
was executed at ilvi w fl,mu,wne) Carleton Funeral Home Inc.
(lumen hen.vem.) 68 Main Streit Hudson Falls NY 12839 and is signed by the funeral director
as witness to its execution.
INJe have received a completed copy of this Authorization Form,
The parsonls) identified below, islare the person(s) in control of disposition, who by signing this
Authorization Form, attest(a)to the accuracy and completeness of the Information contained in this
Authorization Form and authodzNs) the foregoing.
Signed this 30 day of June , 20 20 .
e INT rkor V -�\I • It�+ _
Address
TYN e,Anihe Mme as,mn.
Address
Type W A*wdP&,mh YTR -
Address
WITNESS: I
Cassandra S. Maille Cgut'�" am "+
A„e,wos.emryn.ow Fmeex.m. rurwem.wsyn.m+
14257
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Gloria Amette Fish
WSlaaeli(iev.at/le) NxredCenuW Vge361