Meneely, Elizabeth C. Pine View Cemetery S Crematorium
Quaker Road
Queensburyl NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: _ &ERA _ _ .-- RETURN TIME:
DATE A TIME REMAINS ARRIVED AT CREMATORY: _ _ GBJI"I?o _
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
_ M69K �f
NAME: VITIKA JlWt fV CASE
/N T3 I y
TYPE OF CONTAINERI m*R - (..MI' (i al6 A q rW 6n
PLACE OF DEATH: 33 U I( SH.i; I )d.IP. F11_ j, 11831
ESTIMATED WEIGHT OF REMAINS 8 CONTAINER /so Wf
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION: 4I311D
TIME STARTED: 10:74An THE COMPLETEDI I. MiT41) erI
PLACED IN RETORT: _ OXArl MOVED: IIIyn, )bb�1
RETORT MIN WHICH REMAINS WERE CREMATEDI J4ft % fL PAW
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SHALL BE RETAINED IN THE PeRMAMI NT FILE OF THE CREMATORY.
Authorization for Cremation and Disposition wo �enve :S
Onet v im Fel 99 WeSeiebn AVii
MenL NY IMI
(518)41
LLb.M ate
This Autbodzatlon Form must be completed antl slgnedpdorto dNNery o/remalna M cremation.
Date: 0629/2020 Number: "ill
Crematory Name: Pine View Crematorium
Address: Quaker Road Queensbury NY 128N Phone:
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation is carried out by placing the 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 game will incinerates and
consume everything except bone and metal, which are all that will be leg agar 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 hurt 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 pieces and placed into a
designated container or um; Cremated remains generally are pulverized until no single fragment Is
recognizable as skeletal tiuue.
OPENING OF CONTAINER.
The crematory may only open free container holding the un-cremated human remains in limited cimumstances, 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 container which is not suitable for cremation
such as a ceremonial or rental 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 me transfer or removal of remains will be
conducted before a witness and will be done in privacy, with dignify and reaped.
IDENTIFICATION OF DECEASED
Name of Deceased Elizabeth C. Merely Marital Status:Widowed
Last Known Address: 33 William St., Hudson Fells,New York 12839
Place of Death: 33 William St. Hudson Falls New York 12839
Sex: M V Aga: 89 DOB: 03/3/1931 Dateof Death: 06292020 Estimated VJeigm: 1501W
Description of casket/contalner In which remains will be delivered Matthews Cremation Cam
Cardboard top, plywood mumn
PERSON IN CONTROL OF DISPOSITION
fixerson(sf In writrd ofdiapoafion. Usad ONE M the bllovi
I aml4Ve are the designated agent of me deceased designated in a will or wriflen instrument executed
pursuant to Public Health Law sedion 4201.
R-
VV�Ae have no knowledge that the deceased executed a written instrument pursuant to Public Health Lew
ion 4201 or a will containing directions for the disposition of his or her remains and (canrmuemwxl rivi
Elizabeth C. Mencely
DOdui1(Rev,0111% Nvm aoroexC Feel as
I and we are He parochial having pinery under Pudic Health Law section 4201 and have the right to authorize
crematloh of the remelns of me deceased. MylOur relationship to the deceased is as follows:
(Insert him the fist befo 1
Number: 3 Description: son
1. A person designated in writing pursuant to Pudic Health Law section 4201(3);
2. The surviving spouse;
ga. The surviving dom al partner,
3. Any surviving child eighteen years of age or oldeq
4. A surviving parent;
S. A surviving sibling eighteen years of age or older;
S. A lawfully appointed guardian;
7. Any person(s) eighteen years of age or older entitled to share in the estate and who imare dosest in
relationship to the deceased;
S. A duly appointed fiduciary of the estate',
S. A close friend or relative who has executed a written statement pursuant to Public Health Law §4201Q);
10. A chief fatal officer of a county or a public administrator appointed pursuant to the Surrogates Court
Procedure Act
t0a. 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)
( 'y31ALLTHREEofthe (rm that
e hereby affirm that the vice of the tleceasetl does not contain a battery, battery pack, power cell.
control 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 cremabry and
e atory personnel.
e hereby affirm that instructions have been given to fww.x w.nw�waq Cassandra S. Maille
ending the removal of any personal property or other thing of value which any person signing below or any family
amber of the tleceasetl wishes to preserve rmmwvvr .. f 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 crama0on process and cannot be retrieved
eft6 orientation.
r anon.
Seahereby authorial tmmplwp ) Pine View Crematorium to cremate the
r ma nor of the deceased.
FINAL DISPOSITION
The person authodzetl to receive the cremated remains of the deceased from the crematory is:
Name: Carleton Funeral Home, Inc.
Address: 68 Main Street Hudson Falls NY 12839 Phone: 518-7474243
The cremated remains of tleceasetl will oo disposed of m follows:
13v1urn a/ Ira dLral �u
If for any reason the person named above d trot take possession of the committed remains,
Imnamywme) Plate View Crematory is authorized to give possession of the remains to
p,,,,,,nrmm«,remef Carleton Funeral Home Inc. by delivery in person or by registered mail.
Elizabeth C. Meneely
008-1a r4 coy. at/In) Name Wneceaee0 Pays 2M3
(i d as "awing)
e understand that if the remains are not claimed within 120 days of cremation,
.m,x nwn•r Pine View Crematorium may disposer of the remains in an irretrievable manner,
such as by scatlering.
CREMATION CONTAINERILRN
(Mitiw ONE of the Woo(W)
An um to be used as a writer nor for the cremated remains has been purerouted from
Colorer Formal Home, Inc.. and is described as follows:
IMa understand! that if the um is too small to hold the entire cremated remains, an additional rgkI container may he
used for delivery.
An um has not yet been purchased Drive understand that if no um is purchased or otherwise provided
ronn.n r Pine View Crematorium will place the cremated remains in a rigid temporary
oMainer for tlelivery.
The Authorization Form was provided by rvwmfwecmrnwv; Cassandra S. Maille
was executed at mm.meomesorts Carleton Funeral Home Inc.
tNneni hmme serum) 68 Main Same, Hudson Falls NY 12839 and is signed by the funerel director
as witness to Its execution.
IMe have received a completed copy of this Authorization Form.
The personis) Identified below Islare the persona) in control of disposition, who by signing this
Authorization Form, allest(s) to the accuracy and completeness of the Information contained in this
Authorization Form and authorize(s)the foregoing.
Signed this 29 day or . e 201L .
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Address / t
WITNESS:
Cassandm S. Maille
Fwiwe�paxYw TyWlwffiMeO Nsme Fww&Wncbr Srpnerwe
14257
Mpgapa si
Elizabeth C. Mencely
oosraB4N mr, mnol Name Opwaewtl Fpeaas