Hammond. Michael Carl Pine View Cemetery & Crematorium
Quaker Road
Queensburyl NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: 4 ✓• __... --- RETURN TIME:
DATE A TIME REMAINS ARRIVED AT CREMATORY: 7Im fW ZMPI
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
NAMEI NTCIW YAPN O /_CASE R gig
TYPE OF CONTAINER: W46y - Lie" DI' Lik
PLACE OF DEATH; aW8 eL_SI:Td 1 4a.C1.w. 11 M1 Iar88
ESTIMATED WEIGHT OF REMAINS 8 CONTAINER Zy8 GF / ZtOIl
PLACED IN HOLD:
PLACED IN REFRIGERATION: _ ZI1 S/n
DATE OF CREMATION: -t 7)211) ,TO . . .•
TIME STARTED: �IT'0 64 TIME COMPLETED: q Pp°p7W
PLACED IN RETORT: _�_ib_�__MOVEM Sp. 3U 11' 1')�M
RETORT # IN WHICH REMAINS WERE CREMATED: _ S� gyW t AY
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 PERMANENT PAP OF THE CREMATORY.
NYe OepaNrenl d sate
Authorization for Cremation and Disposition omaonaeemeawe
One Cawarx,i Be WMeggn Annw
(514)474BIIe
vmv.4`5'ex M.ue
This AuMo eon Form must be eompletedandsigrredpdor to delivery ofremai=ror Cr 8VOn.
Data: 07/152020 Number'. 843
Crematory Name: Pine View Crematorium
Address'. Quaker Road Quebromily,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 Rama will incinerate and
consume everything except bona and metal, which are all Nat 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
required by law. The chummed med ramalns will be mechanically pulverizetl into small pieces and placed into a
Designated container or um; Cremated remains generally are pulverized until no single fragment Is
recognizable as skeletal tlasua.
OPENING OF CONTAINER.
The crematory may only open the container holding the 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 container which is not suitable for cremation
such as a commontal or rental call the crematory will require Nat the remains this moved into a suitable
container before It accepts Na 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 respect.
IDENTIFICATION OF DECEASED
Name of Deceased Michael Carl Hammond Martial Status: Munied
Last Knmvn Address: 27 Division St., Hudson Falls New York 12839
Plac/a'el(\DeaM'. 3668 B SL Yorktown, N York 10588
SaE MI F Age: 63 DOB'. 04/27/1957 Dateof Death: 07/132020 Estimated Weigh: 240Il
Descri/ption of casketicpntainer in which remains will be delivveretl:
Matthews Cremation Case, cardboard top&, betmm
PERSON IN CONTROL OF DISPOSITION
(Powe iin causal of ducereirbn, Natal ONE of Me /eAMeMig)
I am/We are the designated agent of the deceased designated In a will or written Insimment executed
pursuant to Public Health Law section 4201.
Ihave n knowledge that the deceased executed a written Instrument pursuant to Public Health Lew
section @01 01 or
or a will containing directions for the disposition of his or her remains and (Darkened Mat wae)
Michael C. Hammond
DOB law I flue..atrial Nvn.00wimi veB. l ma
I ant we are the person(s) having priority under Public Health Law section 4201 and have the right to authorize
cremation ofthe remains of Ma deceased. My our raladonship to the deceased is as follows:
(10"d lrom the list below)
Number'. 2 Description'. wife
1. A person designated in writing pureuant to Public Health Law section 4201(3);
2. The surviving spouse;
as. The surviving domesfic partner,
3. Any surviving child eighteen years of age or alder;
4. A surviving lasers;
d. A surviving sibling eighteen years of age or older;
6. A lawfully appointed guardian:
T. Any person(s) eighteen years of age or older entitled to share In the estate and who is/am closest in
relationship to the tleceasetl:
8. A duly appointed fiduciary of the estate',
9. A close friend or relative who has executed a written statement pursuant to Public Health Law§4201(7);
10. A chief fiscal oIDcar of a county or a public administrator appointed pursuant to the Surrogate's Court
Procedure Act
10a. Any other person who is acting on behalf of the deceased and who has executed a written statement
pursuant to Public Health Lew §4201(7)
GALL THREE ofine following)
Ime hereby affirm that the body of the deceased tices not contain a battery, battery pack, power cell,
radioactive implant, or radioaMive 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.
-Il 8 hereby affirm that instructions have been given to lr"miereci Cassendre S. Maille
regarding the removal of any personal property, or other thing of value which any person signing below or arty family
member of the deceased wishes to preserve. Im+aM�q Pine View Crematorium I not
responsible for removal of personal items from Ore container or from the remains of the deceased. Personal Nems
left in the container or with the remains will be destroyed by this orientation process and cannot be retrieved
after cremation.
l .11'Ne hereby authorize tmmwmrnarw) Pine View Cremamrfum to cremate the
remains of the deceased.
FINAL DISPOSITION
The Parson authonzed to receive the canceled remains of the deceased from the crematory is:
Name: Carleton Funeml Home Inc
Address: 68 Main Street, Hudson Falls NY 12839 Phone: 519-7474243
The cremated remains of deceased will be disposed of as follows:
Returned to family
If for any reason the Person named above does not take possession of the cremated remains,
rmmwwxo.,ml Pine View Crematory is authorized to give possession of the remains to
rrVmwnmenfi i Carleton Funeral Home. Inc. by delivery in person or by registered mail.
Michael C. Hammond
Oosleesai ifew OVIOI Aw.mO.an.w Fare 2 cc
i
l
e understand mat H We remains are not claimed witAin 120 days of cremation,
rcememxn.mt Pine View Crematorium may dispose of the remains in an irzetdevable manner,
such as by scattering.
CREMATION OONTAINERIURN
(Initial ONE of ate (allowing)
An urn to be used as a container for the chartered remains has been purchased from
C Iemn Funeral Home Inc.. and is described as follows:
INtle understand that if the urn la too small to hold the entire cremated remains, an additional rigid Container may be
used for delivery.
An um has not yet been purchased IWO understand that if no um is purchased or otherwise provided
rmmabryname Pine View Crematorium will place the prompted remains in a rigid temporary
containerfordellvery.
The Authorization Form was provided by Cassandra S. Maille
was executetl at rlmerw mme nevi Carleton Funeral Home Inc.
pmwIel none eaeneet 68 Main Street Hadson Falls NY 12839 and is signed by the funeral director
as witness to As execution.
INve have received a Completed copy of this Authorization For n.
The parsonta) Identified below Ware the person(a) in control of disposition, who by signing this
Authorization Form, adestla) to the accuracy and completeness of Me Information contained In this
Authorization Form and authortzels) the fofagoing.
Signed this 15 day of July M 20 .
E � lyn
Address
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WITNESS:
Cassandra S. Maille l do[ 0
FwnNWMw TyHaw PnMM Nwme FvmelW+do'sgnabue
14257
RgivYe4'n'r f4vnM'
Michael C. Hammond
306-1" ulaev. 011101 Name OrpennM nPtaa