Hall, Loretta Mary Jane Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (513) 745-4476
FUNERAL HOME: LA�I4E{O) _ RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: _ 7III ITO 2'36�7
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
mntu 11? ask 4
NAME: AC1 gill _I CASE R 91'Tl
TYPE OF CONTAINER:
PLACE OF DEATH: °l NS Y'IIj 1�bEe1 IIyI
ESTIMATED WEIGHT OF REMAINS & CONTAINER
PLACEDIN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION: 7IitI To
TIME STARTED: -MI TIME COMPLETED:
�?' {G�0 4:66/Sy
PLACED IN RETORT: �yL4ti_MOVEO: BwanI R,M6M11
RETORT Y IN WHICH REMAINS WERE CREMATED'. W9 &LIC FAII
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN qS HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE:THE CREMATION LOG SHALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
Authorization for Cremation and Disposition "Yor°,4io�<(�:',hi
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This Auf melon Form must be completed and SlgnedpHMW delivery oframabuforCre 8 n.
Data: 0712I/2020 Number: 41/.f
Crematory Name'. Pine View Crematorium
Address: Quaker Road Queemil NY 128N Phone:
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation is canned! 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 game. The heat and Rama will Inchworm and
consume everything except bons and metal, which are all that will be left after cremagon.
Following cremation, the crematory will take reasonable efforts to remove all of the remains and other material from
0re cremation chamber, but same 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 unmated remains will be mechanically pulverized into small pieces and placed into a
designated container or urn', Cremated remains generally are pulverized until no Single fragment is
recognizable as skeletal genus.
OPENING OF CONTAINER.
The crematory may only open the container holding the un-cremated human remains in limited circumstances, such
as to confirm the identify of the deceased or to ensure that no maenal 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 caskel the crematory will require that the remains be moved Into a suitable
container before It accepts no remains. The opening of a container or 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: Lorena Mary Jane Hall Mantal Status: Widowed
Leaf Known Address: 50 Luzerne Rd Qzxmpbury,New York 129M
Place of Death: Glens Falb Hospital, Glens Falls,New York 12801
Sax: M 0 Age: 81 DOB: OV14/1938 Drafted Deal O7/19/2020 Estimated VVeighC 1919
Description of caskeVcontainer in which remains all be delivered. Matthew's Casket Company
Cardboard top, plywood bottom
PERSON IN CONTROL OF DISPOSITION
(Penal In cza lofdepasilpn, iNrial ONE of Me falkwhar
I am/We are the tlesignatetl agent of the deceased designated in a will orwritten instrument executed
pursue to Public Health Law aeaion 4201.
IMe have no knowledge that the deceased executed a written instrument pursuant to Public Health Law
201 or a will containing directions for the disposition of his or her remains and (cw,anuan nex pang)
Lorena Mary Joe Hall
ooa98Ge P mail mnm wife albnxee page Ws
I any we are the pers in(e) having pdonty under Public Health Law section 4201 and have the right to author"
cremMiondM mmainsoflhedeceased. My/Our relationship to Me deceased is as follows:
(Insert lmm the list belay)
Number 3 Description da i
1. A person designated In writing pursuant to Public Health Law motion 4201(3):
2. The surviving spouse:
2a. The surviving domestic partner;
3. Any surviving child eighteen years of age or older;
4. A surviving parent
5. A surviving sibling eighteen years of age or older,
6. A lawfully appointed guardian:
y. Any person(s) eighteen years of age or older entitled to share in the estate and who Was closest in
relationship to the tleceased:
B. 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 0scal officer of a county or a public administrator appointed pursuant to the surrogate'a Court
Procedure Ad;
I am. Any other person who is ailing on behalf of the deceased and who has executed a written statement
pursuant to Pudic Health Law§4201(7)
ALL THREE o(Me Ii nthe
IfTH hereby aRrm that the body of the tleceased does not contain a battery, battery pack, power cell,
ore implant, or radioactive device and that any such materials ware removed prior to the execution of this
t
ation Form. Failure to remove Mesa Items prior to emanation may result In harm to Me crematory and
ry personnel.
IMIe hereby affirm that instructions have been given to is e,v .nwnmmn Paul M. Dietrich
g the removal of any personal property or other thing of value which any person signing below or any family
of the deceased wishes to preserve lmm•mrvum) Pine View Crematorium is not
responsible for removal of personal items from the container or from Me remains of the deceased. Personal home
In the container or with the remains will be destroyed by the cromation process and cannot be "loved
remotion.
IlWe hereby authorize (mmamn woe Pine View Crematorium to cremate the
re a of the deceased.
FINAL DISPOSITION
The person authorized to receive the crammed remains of the deceased from the crewel IS:
Name' Carleton Funeral Home, Inc.
Address'. 68 Main Sol Hudson Falls NY 12839 Phone: 518-747 4243
The pre
remains of tleceasetl will be disposed of as ollowa'.
, f E
If for any reason the person named ab tloas not take possession of the cremated remains,
faem row�m,w) Pine View Crematory is authorized to give possession of the remains to
Mmremom.�.me) Carleton Funeral Home Inc. by delivery in person or by registered mail.
LorefthriaryJane Hall
pos-)waN Ps, atnm wi Pull
Im I 1 Me following)
Me understand that if the remains are not claimed within 120 bays of cremation,
same) Pine View Crematorium may dispose of the remains in an irretrievable manner,
such as by scattering.
CREM1UTION CONTAINERFURN
u2sai id ONE of the fallowing)
An um to be used as a container for the cremated remains has been purchased from
Carleton Funeral Home, Inc.. and is described as follows
IfWe understand that if the um is too small to hold the entire cremated remains, an additional rigid container may be
used for delivery.
tAn urn has not yet been purchased. lMe understand that if no um is purchased or otherwise provided
I be acme) Pine View Crematorium will place the cremated remains in a rigid temporary
corminer for delivery.
The Authorization Form was pwided by auamlm,.=m.aeae) Paul M. Dietrich
was execNed at awaw aware amel Carleton Funeral Home Inc.
(fu....I mn. uu. ) 68 Maw Street Hudson Falls NY 12839 and Is signed by the funeral director
as witness to its execution.
IANe have received a completed copy of this Authorzation Form.
The personls) Idengfied below Ware the pershams) in control of disposition, who by signing this
Authorization Form, attesm) to the accuracy and completeness of the information containetl in this
Authorization Forma and authorizes) the foregoing.
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WITNESS:
Paul M. Dletnch
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Loretta Mary lane Hall
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