Morrow, Jane Marie Pine View Cemetery & Crematorium
Quaker Road
Queensburyl NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: AIGtL RETURN TIME: ���/y�
DATE B TIME REMAINS ARRIVED AT CREMATORY: 7I41 kl 7130M
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
K14. I;h DIAS✓I
NAME: gnoi. MOEQOU a CASE
TYPE OF CONTAINER: GIFB0d
PLACE OF DEATH: "Mr iJ kY( FB I
ESTIMATED WEIGHT OF REMAINS S CONTAINER I� 156 N�
PLACED IN HOLEY
PLACED IN REFRIGERATION: 7AC IN
DATE OF CREMATION: -J 1Y11O
TIME STARTED: 10:y F/1,..f1,,L.1, TIM[ COMPLETED: n+�
PLACED IN RETORT: lIAe /III MOVED: 0 �366hj v orp
RETORT R IN WHICH REMAINS WERE CREMATED:
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SMALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
_ Authorization for Cremation and Disposition No wommi State
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This AUMorkaaon Form mwfM [ompyatad slanedpdorro defia of r013 mf cIN31MM13.
Date: IIt 11A Number on
Crematory Name: Pine Vk Crematory
Address Quaker Road, Qu nsbury, Naw York 12804 Phone: 5181745-0477
CREMATION IS AN IRREVERSIBLE MO FINAL PROCESS.
Cremation is carried out by placing the remains of the deceased and the container holding the remains into a
crefirrination chamberwherethey are subjected to'mteme heat antl}lame.The Mat and flame atoveneMe and consume
"KyNlly except MM art metal,which are all that will M left of ter cremadon.
Following ere ml the crematory will take tease nafile efforts to n of the remains and other material from the
orearrattom chamber, but same minimal dust and residue will likely be]am behind The crematory will separate incidental and
foreign material from the remains and the momental and foreign material will be disposed of as reywr in by law. The
cremated remains win be mechanically pulverized into small poices and placed into a designated trimmer or urn.Cnmaled
remains generally are pWval3ed wMl no single kagment Is recgn Me as sWN tissue.
OPENING OF CONEA1NER
The crematory may only open the container holding the un-cremated human remains in limit" circumstances,such as to
confirm the mentny of the deceased or to ensure that no material is enclosed which might injure employees or damage
crematory property. if hull amNns re dNWertd In a mMNner whkh k rot iNMe W fwrem cation such xi a rerem q pnlalmea lcasket,the cr Mory will require that the remains be moved Into a suMble cemaimr Move A os the remains.The
opening M a container or transfer or removal of remains will be conducted before a witness and will be done in privary,
with dignity and respect.
IDENTIFICATION OF DECEASED ,(�
Name of Oecaaaed: , dvJnT / /gyf,l f � (U Ma[((.U'' ss ) ,f Mantel Statue: la,), I\
Last "own Mdraas. � G aSD 3t.c d Sr Sli AkN.. Y��
Place of Death v ' 1 Pr ?�L
Sex: oat 111f Age: P '2DOR: 3 DMoof Death 7/4 J,yQ Eatlmaled WagM: JSD 5-
Description of casket/container in which remains will be delivered-
Corrugated Cardboard Box with Plywood Starmark Model If 38808
PERSON IN CONTROL OF DISPOSITION
(Persal in control of disposition, initial ONE of the fallowing)
I am/We are the designated agent of the deceased designated In a will or carmen monument executed pursuant M Public
Health law section 4201.
-OR-
ll/hed dhave no knowledge that the deceasedrt exeed 42 a written instrument pursuant to Public Health law section 01 or
will containing directions for the disposition of his or her remains and (COMInuM read pal
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Sri arise ii amne4uame3 PWI03
✓ lam/we amthe persons) Minng p(ro(M under Public Health Law section 0201 and have the right to authorize vemrtbn
of the remains of the deceased. My/DureltllanAip toMe deceased! Is ufatest:
anuitfrom the on below)
Numbl Description:
Apersondesignatedinwnbngwmrs ao Pudic HeaMLaws n4201 (3);
2. Thesurvivingspoucel
b. fire
3 Anysu gcgch'Ideghteeny orn olds,
4. ANormap parent;
S. Asomivir blingeighteenyeanaageorolda;
G. A lawfully appointed guardian:
T. Any personbuffighteen reproof ageoroMere Mt inshore in MemM andwbo islareclosestin
relationship to the deceased,
e. A duty appointed fiduciary of Me estate)
9. A close friend or reladve who has executed a written statement pursuant to Public Health Law §4201(]);
10. A chief fiscal officer of a county or a public administrator appointed pursuant to Me Surrogare's Court
Procedure Act:
10a. Any affair person who is acting on behalf of the deceased and who has d ecutstl a w n treatment passed
as Public Health tew§4201(7).
(Mi massy thefd rims)
I/we hereby affirm that the body of the deceased does not contain a battery, battery perk power cell,momentum
implan[ or radioactive desire and that any such matease were removed prior to the execution of this Authorization Form.
Failure to remove these Items prior to mergers mry souk In Mmr to the tmmaary and tsemamy removal
InI/V/e hereby affirm that instructions haw been given to puzmamvw.emel Cwoo RafleM#141W regardingthe
of any personal property or Dither thing of value which any person signing hlow or any family member of the deceased
wishes to preunre. anirvi PneVeraCrematory is not responsible for removal of personal
items from the tontalner or from the remains of the deceased Personal Items laid In the conbMer or card the remain will be
destroyed by the owned"power and cannut be rMieved after overseas.
§}y���yyI�1 Ii hereby mechanism ramuwvmmel Pine Vlew Gpma(oN IDc hen Mer mof
th e`eased.
FINAL DISPOSRIDN
The person summered to receive the uemated remains of Me deceased "in the CRmalory is'.
Name'. Baker Fungal Home Personnel
Approve: 11 Lafavette Street Dueansbury New Yak 128N phone (518)781-9303
TM cremated remains of deceased will be dispmed eras folbws'.
Return N family to be decMed
If far any reason Me Person named above does net oke pMsession of the cremated remains,
(winnow,•nwn Pine View Crematory is authorized b give possession a Me r In
rNremue...enel Baker Funeral xpme by delivery in person or by registered mall.
Inirilew.wol �, Adrtu tF�. 1 ra•itdit nDmm.
' IrhejollowN9)
iNJe understand that XMe remains are not di in ed within 130 days of cremation,
l�ww•vre1 P'ne V'rew Cremator m dispose of Me remains in an in eveWe manner,
such as by scaddring.
CREMATION CONTAINERNRN
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An urn to M used as a whitener M the cremated remains has keen purchased from Baker
Funeral Home and is descdtea as follows:
IAW understand that Rthe um Is too small to hold Me entire cremated remains, an additional ourd container may M used
far delivery.
7R
y N/ 1. An um M has not yet en pumxd ha . LAND undettaM m Met if no u is Wrchro e f or demanders provided ta.mmay
�`� Pena Yew Cremabry will place the cremtled remains in a tigE temporary
cantainer for deliver.
This Authorization Form was provided by durvwsano..sel Upsa Raffertv#14100
was executed a Uwe eaMmo-1 Baker Funeral Hame
ryriw.lno.re.ea a t l Mtavetle Strew[ Oueensburv. New Yak 1200a and is signed by Me funeral director
as vnMess to its erecutm.
Whe have received a completed copy of this AuMorsalion Form.
The persons) iclenlRntl besides isrere Me peraon(s) In domfolwdsposrtion "a by signing this Audianzetion
Farm, abast(s) to the accuracy and cahpleteness o{Me in ormaXon confamed in this AUMorromado Form add
a dirroh e(s) Her, foragoag
Sign`�this dayof UL m � ✓y,�
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WITNESS'
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Funeral Home Red. AKI130
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