Van Valkenburg, Michael Joseph Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745.4477 or (518) 745-4476
FUNERAL HOME: _ OP W P _ RETURN TIME: /�F�DATE & TIME REMAINS ARRIVED AT CREMATORY: W-2bl zO boo pm
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
NAME: _ IOTA [A VAU �(VALKB*f4ASE R —77�
pa
TYPE OF CONTAINER: C Bw L1GUM / W- 54ENy[ t*4jt �lo
PLACE OF DEATH: u0n VAU64 NUR NE ND
ESTIMATED WEIGHT OF REMAINS & CONTAINER 16y OC
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION: -7h112 �y L,
TIME STARTER _) PQ�D H TIME COMPLETED: j' II6F\II
PLACED IN RETORT: F'Gbpn MOVED: 9:pAti
RETORT R IN WHICH REMAINS WERE CREMATED: AaY RHii,mv
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE:THE CREMATION LOG SHALL BE RETUNED IN THE PERMANENT FILE OF THE CREMATORY.
Authorization for Cremation and Disposition " avers,"
D mmnew,a� . ra, wF�`geavi
wlsnii.7>s2.e
The Aulhoneation Form must bus eonWa aM mgm prior m seaman'of remains for prtl m,
Date: 6/3D/7y Number -711
Crematory Name: Pine Yaw mtory 1 Crea m
Address-- Quaker Rpaq Queansbury, New Year 1280d, Phone: 51fl1T45-04TT
CREMATION IS AN IRREVERSIBLE AND FINflL PROCESS.
Cremation Is carried out by placing the remains of the deceased and the container holding the remains into a
cremation chamber where they areea subjected to Intense htandflame.The Beef and opposes
a flam ""incinerate and
areMhing except bone and meal,wNN Be all MM will be haft after cremation.
To[law lfig cremation, the crematory will take reasonable efforts to remove an of the remains and MMr material from the
the oration chamber, but some minimal dust and hold ue will likely be left be Inind.The crematory will separate incidental and
forego 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 pieces and placed into a designated Container or urn. Crem
remains generally are pulrmil until rw shale fragment is r¢ imb[e as skeleal tissue.
OPENING OF CONTMNER
The crematory may only Open the container holding theun-cremated human remains In limited circumstances, such as to
confirm the identhy of the deceased or to ensure that no material Is enclosed whim might njure employees or damage
crenctorypropeatty If human remains are dNNe Ina contzimrwNm is not suitable for PemaMn suchas a ceremonial an
rental bagel,llw crtmalary"I require remainsNattM be moved Into a suflablemntainerbefb rein re It acceptsthe damage.The
opening of a container or the transfer or removal oemains will be conducted before a witness and will be done in privap,
with dignity and respect
IDENTIFICATION OF
DECREASED
NamemDd Martal stam:rhii Cie
�
Last Known Addreas:'i t iei C wAgai %)A%N�#4 , 0 &xsle,` Ny 12 f 4�
Plata or Deem i vs6ii ar';trv.
Sex: XM of All Aiy y, Dmeor oaam: yf j F_atimereavueigm: I1�51 {�g
Description of neget/corminer in which remains al be delivered:
Corrugated Cardboard Box with Plywood 5tarmark Model N B M
PERSON IN CONTROL OF DISPOSITION
(Person(s) in central of disposition, initial ONE of the following)
I am/we are the designated agent of the deceased designated in a will or written instrument executed pursuant to Public
Heats taw section tOO1.
-OR-
p Ve have per knowledge that the deceased executed a written instrument pursuant to Public Health taw seRlon 4201 or
will containing directions for the disposition of his or her remains and (Continuetl next page)
V, �1A1�t A
wsuxr-11aw.ovWl q'�8� vwesms
lam/we am the persnnls)having priority under Public this¢b Law seztion 4201 and have the right to authorize cremation
of the remains of the de¢aaed.My/Wrre atlonship t0 the deceased is as follows:
(Insert/rtvn the UA ordered ,�{(\\�T
NumbM�l)wvmptian: LXi�
A designated! in writing pumusentim Pilings Health lave seclgn 4201 (3);
The surviving sppuree;
2t The surviving tlomeslic partner;
3. Any surviving child eighteen years of age or older;
4. A surviving parent,
5. A surviving siGing eighteen years of age or alder,
S. A lawfully appointed guardian;
T. Any parsons) eighteen years of age or eWer endge l to share in the estate and who Islare closest in
relationship M the deceased;
g. A duly appointed fiduciary of Me estate;
g. Achose fiend or relaMe who has exeuttetl a written statement pursuant to Public Heath Law§4201(7);
10. A chief fiscal officer of a county or a public administmlor appointed pursuamM the Surrogale's Coud
Procedure Ac41
III Any What person Me is acting on behad of the deceased and who has executed a written statement pursuant
W Public Heal Law§4201(]I.
gagii 1i ofthe)olbwing)
/"4 I/We hereby affirm that the body of the deceased does rest center a battery, battery pack, power cell, radioactive
implant,or red inactive device and that any such eastern were removed prior to Me execution of this Authodzrtion Farm.
Failure to remove these Items prior to amatbn may reek In harm to the crematory and crerrebry perorinel.
act I/Wehere by affirm t hart instructions have been given to pw.emmv,,w ,,I [osslo Ra/ #141W rep ran ng the
removal of any pe come I property or other thing of value which any person signing below or any family member of the deceased
whicestomeserve. wmemnm.el Pine View Cremators, is not responsible for removal of personal
items from the container or from the remains of the deceased. Porxnel Rams left 10the somewhat or were Me rmralm will be
dertmyM by the cremation pmmss and annR be rebleved Offer cremation.
�� p 1I herebyauthorim L.mwmvmel Pine MacyCrematory cremate the remains of
tie emasea.
FINAL msPOSMON
The parson auMortzed In receive the cremated remains of the deceased from Me crematory, is:
Name. Barker Funding H Posestannel
Address: 11 lartervere Sionsect Quesensbury, Phone I511d 761A303
The cremar[a remains of deceased will be deposited of her folder:
Relum to Family W be decided
If Or any reawn the perse r named above doer net take possession of the cremated remains,
(ovrurpy narn) PNI VIW CRme101y
a authorized W give mmsrinn OFMe remains
pMewaevemi Baker Funeral Neme by delivery In N preerson or by registered mail.
\)P1 V `�\oJaB FN.rrl nP'.04ro1 � wei
(ja¢(¢f melonowtnel
INJe understand Mat if the remains are teat ch imad within 120 days of cremadon.
rm ,,zi Pine View Gnmaom may dispose of Me remains in an inetrbvabk manner,
such as by anebering.
CREMATION CONTAINERAIRN
In Na pNE o)tne jolbwirgl
An urn fo be used as a container for Me cremaled remains has been Purchased from Baker
Funeral Home and is described as falows:
IMIe understand Mat if the urn is too most M hold Me entire compoed rerrearm an addhonal right commuter may be used
for delivery.
OR
An um has not yet been purchased IMP understand that R no um re purchased or otherwise provided rmmum'
Pine Yew Crematory will plane the crematetl remains in a rigid tempprary
container far delivery.
This Authorization Form was providetl by rx..ow .xwl Gss'a Rafferty 41010a
was executed at awnwwnemm:t Baker Funeral Home
rwzamhmre.ea.ml 11 Lalavette Shee( Oueensburv. New Yak t2801 eM is signed! by Me funeral director
as witness to its exeNlion.
IMAe have recaNed a oampleled copy of this Authorization Fotm.
The peens lMenbfreo'before iNam Mr person(s)in contend ddisposNwr, who by signing his AUMaizabon
Form, aenest(g to May acoumil word completeness tithe metionabon communed in Mis AUMpn4atlon Farm and
auMwlze(s) this yoregaing.
S y pls rts deyor LIaC .
b zT ENV A pp<
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maw am. :bwm
sent.+
WITNESS'
Caala ReRelly ( \<
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Funeral Home Reo 1y01130
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