Clark, Kelly D. Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: IAMM _ RETURN TIME:
DATE B TIME REMAINS ARRIVED AT CREMATORY: 7I2I PO /D'OM
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
&I ELT Du
NAME: IGW Apa CASE IF IC6
TYPE OF CONTAINER: MI46j - 1/ /MIA (Q( ' e;Av 1 / / ��
PLACE OF DEATH: S.Jlir R*iIi1
ESTIMATED WEIGHT OF REMAINS 8 CONTAINER IW I4 /YNIIP
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION: 7II112 GA.H
TIME STARTED: II' IDI♦M TIME COMPLETED: I' �- P
PLACED IN RETORT: II '7VArl MOVED: ILPDPi'II ITI(A1 IQ"�y''�IIM�Hty1
RETORT Y IN WHICH REMAINS WERE CREMATED: SjrfA.NLlY I'^I:1
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SHALL BE RETURNING IN THE PERMANENT FILE OF THE CREMATORY.
xx
Authorization for Cremation and Disposition °,�aCnm�;
OneG M""Rya,W W Minim n Amin
Abny, NV IM31
(518)<YSLa
wnw.We.eM.^y�
Thls Aupmrl2a r-orm must be camnWeadandalgnedprtor to delivery ofranans far emanates.
Date: W30l Number 'M
Crematory Name: Pine View Cmiturodum
Address: Quaker Road, Queemil NY 128N Pitons: Yl
CREMATION 15 AN IRREVERSIBLE AND FINAL PROCESS.
Cremation is carried out by placing Me remains of the deceased and the container holding the remains into a
cremation chamber where they are subjected to Intense heat and flame. The heat and Dame will incinerate and
consume everything except bone and mend, which are all that will be left attar cremation.
Following cremation, the crematory will take reasonable efforts to remove all of the remains and other material from
Me cremation chamber, but some minimal dust and residue will likely be left behind. The crematory will separate
material and foreign material from the remains and the indtlennl and foreign material will be disposed of as
required by law. The cremated remains will be mechanically pulverized into small pieces and placed into a
designated container or um: Cremaned remains generally arc pulverized unit[ no single fragment is
recognizable as skeletal Mount.
OPENING OF CONTAINER.
The crematory may only open the container holding the un-cremaled human remains in limited drwmstances, such
as to confirm the identity of the deceased or to enure that no material is enclosetl 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 wremonial or rental casket, lea critical will require that lee 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 he done in privacy, with dignity and respect.
IDENTIFICATION OF DECEASED
Name of Deceased: Kelly D. Clark Marital Status: Marred
Last Known Atltlress: 19 Culver St. Fort EdwNrd,New York 12828
Placeof Death: S miteH iW Sarno S ino New York12866
Sex: M FO Age: 52 DOB: 06/07/1968 Date of Deatb. 06 8/4020 Estimated Weight: LZOIhc
Description of ws gwntainr inwhich remainswill be delivered: Mathews Cremation Cese -cadboardmp
and bottom
PERSON IN CONTROL OF DISPOSITION
(Pasan(sl in coned amble designated
ONEMne loedece)
I am/We are Me designated agent of the deceased designated in a will or written instrument executed
pursuant to Public Health Law section 4201.
R-
LWe Have no knowledge that the deceased osconexecutedo ais or h instrument pursuant m Public Health Lew
section 4201 or a will containing directions for the tlispoeltion of his or her remains and (CmSmrednextpepel
Kettle D. CNrk
CP41e66111aw.orris) `vvw& FNn IN
fpseed the ldbwinnl
WZ_ WIl understand that if the remains are not claimed within 120 days of cremation,
rwwmiwreamw Pinc View Crematorium may dispose of the remains in an instri wade manner,
such as by scattering.
CREMATION OORTAINEWURN
(Inn=al ONE of Me rolbwingJ
An an W be used as a container for Me aemp sd remains has been purchased from
Carleton Fucoml Home Inc.. and is described as follows:
IhVe understand that if the um is too small to hold the entire cremated remains, an additional rigid container may be
used for delivery.
-OR-
l� An um has not yet been purchased. IANe understand that If no um is purchased or otherwise provided
(Oww i Pine View Counsel aril place the cremated remains in a rigid temporary
comainerforcar ery.
The Authorization Form was novel by Cass S. Mnille
was executed at ovw,we maw Carlearn Funeral Home,Inc.
au„ww vw*e ercxl a Main Street Hudson Falls NY 12839 and is signed by Bre funeral director
as witness to he execution.
lMe have received a completed copy of this Authorization Farm.
The parson(s) identified! below ialare the personla) In control of disposition, who by signing this
Authorization Form, anesgs)to the accuracy and completeness of the Information contained in this
AUModzation Form and outhorixe(s) the foregoing.
this 30 day of June , 20 20
M � WLL
w
19 Cil
Andrea
TiwawPs9eNne Senate,
Address
TRew RUXM IYme °4�waT
Andreas
WITNESS:
Cassandra S. Maine
Fmw'MOHMwTWa1w RFWNaw Gwe,w PMb99wttn
14257
a.aaawmemaea
Kelly D. Clark
ooaleal lw.. omw wewaow..ae eNeswa
I arm we are the per ort s) having priority under Pudic Health Law section 4201 and have the right to authorize
cremation of me remains Atha deceased. My/Our relationship to the deceased is as follows:
(Insert Arm this IIN below)
Number: 2 [)ascription'. Husband
1. A person designated In writing pursuant to Public Health Law section 4201(3);
2. The surviving spouse;
ga. The surviving domestic partner,
0. Any surviving chief eighteen years of age or alder;
4.A surviving parent;
5. A surviving sibling eighteen years Of age or older;
S. A lawfully appointed guardian;
T. Any persons) eighteen years of age or older entitled to share in Me estate and who is/are closest in
relationship to Me deceased:
e. A duly appointed fiduciary of the estate;
9. A dose friend 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 Surogate's Court
Procedure Act:
10a. Any Other person who is acting on behalf of the deceased and who has executed a written statement
pendent to Public Health Law§4201(7)
(Intel ALL THREE&(be following)
IN:hereby affirm that Me hotly of Me deceasetl does net contain a battery, battery pack, power cell,
tive im rediaecplant, 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.
W_(� We hereby affirm that instructions have been given to ls..,aaaxrovmm l Cassandra S. Maine
regarding the removal of any personal property or other Ming of value which any person signing below or any family
member of the deceased wishes to preserve. (m vxvnmvff Pine View Crematorium is
sact
responsible for removal of personal items from Me container whom the remains of the deceased. Perxonalitems
left in the container or with Me remains will b s destroyed by the cremation process and cannot be retrieved
after cremation.
9Q�, Mi hereby autlm y rimrmimmere m ml Pine View to cremate the
remains of tha Eeceaseit.
FINAL DISPOSITION
The barmen authorized to receive the cremated remains of Me deceased from Me crematory is:
Name: Carleton Funeral Home Inc.
Address: 0 Main Street Hudson Falls,NY 12939 Phone: 5111-0494243
The cremated remains a deceased will be disposed of as follows:
g"+"Len
to 4 I
If for any reason the person named a tices not take possession Or the cremated remains,
toanemyremel Pine View Commodity is au ivermad to give presseasion of the remains to
pw,w.wmm.,wme1 Carleton Funeral Home, tnc by delivery in person or by registered mail.
Ke0yD Clark
oas.lesuu laay.omo) xmwdo.uesN epe2da