Hogan Sr., John F. Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: _ WASEP RETURN TIME hsfl{
DATE & TIME REMAINS ARRIVED AT CHEMATORT; ,_„__ -Ih4I7o 10,401
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
NAME:
TYPE OF CONTAINER: (u/ ���- 40t nmor - [a Ilwy M
PLACE OF DEATH: _� r tv. _9-4r
ESTIMATED WEIGHT OF REMAINS & CONTAINER_ 7{(' Iy. Isrok('
PLACED IN HOLD:
PLACED IN REFRIGERATION: _
DATE OF CREMATION: 7I24I'�! ppy,
TIME STARTED: _ ICro�.]f TIME COMPLETED: I�p ' I�iTI
PLACED IN RETORT: _.-_ Ilad'/Kj __MOVED: l-M (j:(C
RETORT p IN WHICH REMAINS WERE CREMATED: &L MI Tr
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.
Abthorization for Cremation and Disposition o`,oice�nkre�,
O%Connnmu Piece,0 Wurtiybn Avenue
Alseny.NY IMI
(518)O4
eow.aw.Neri
This AWhorizadon farm must be compMW wdslgnedpdorto delivery of remains forcrwnadon.
oats: 712NIw Number SG.�
-s
Crematory Name: Pine View Cremstmium
Address: Quaker Road, Queerubury m12804 Phone:
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation is named out by placing the remains &the deceased and the container holding the remains iMo a
cremation chamber where they are subjected to intense heat and flame. The heat and flame will incinerate ant
nsume everything except bona and metal,which are all NOR will be Iteft after cremation.
Following cremation, the crematory will lake 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 cremated remains will be mechanically pulverized into small pieces and placed into a
designated container or um; Cremated remalns generally are pulverized until no single fragment Is
recognizable as Well tissue.
OPENING OF CONTAINER.
The crematory may only open the container holding the un-cremated human remains in limited circumstances, suds
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 remalns 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 M a container or the transfer or removal of remalns will be
conducted before a witness and will be done in privacy, with dignity and respect.
IDENTIFICATION OF DECEASED
Name of Deceased: 1 r9 N Iv� ) (' �0�' 'r v7 ' Ls�4 Martial Status: �(�,.
Lan Known Morass:
' 15I L3 t+ct VP 1VBU, oltve 1 r", ✓yFh l ` [IJ �µ I If-ff.
Place of Cash: J3 ndw`J o"I / t4 d I'( )J 'i 'F< (t( ✓I f/ 1L�
se(M) F Age: -1y DOB: �<Do* of Death: a 4WEstimeted VJeigMzd�c_
Description of wskeVmMairrer in w�h�ich remains will biz delivered: C
PERSON IN CONTROL OF DISPOSITION
(Pemon(s)M confrof W dispositon, inln=al ONE of Me/ollowirg)
I am/We are the designated agent of the deceased tlesignated in a will or written instrument executed
pursuant to Public Health Law section 4201.
1Wde have no knowledge that the deceased executed a written instrument pursuant to Public Health Law
4201 or a will containing directions for the disposition of his or her remains and (cmnnuedm»papal
J L
vo&Ie (se, avlo) xmeolUereswe ta]
I ant we are the persons) having priority under Public Health Law section 4201 and have the right to authorize
cremationofiheremainsofth¢ deceased. Myron relationshipto the deceased is asfolloval
(Insert shorn the list hall
Number: .1 Description :Z— IdyK
1. A Person designated in writing pursuant to Pudic Health law section 4201(3);
2. The surviving spouse:
U. The surviving domestic partner:
3. Any surviving child eighteen years of age or older,
4. A surviving parent:
S. A surviving sibling eighteen years Of age or older;
6. A lawfully appointed guardian;
T. Any persons) eighteen years of age or older entNad to share in the estate and who islare closest in
relationship to the deceased;
8. A duly appointed fiduciary of the estate;
9. A close friend or relative who has executed a written statement pursuant to Public Health taw §4201(7);
10. A chief fiscal officer of a county or a public administrator appointed pursuant to the Sumogate's Court
Procedure Act:
10a. Any other person who is acing on behalf of the tleceaeatl and who has executed a written statement
pursuant to Public Heats Law §4201(7)
(���In4r A L THREE of the fallowing)
NNe hereby affirm that the body of the deceased does not contain a battery, battery pack, Power cell,
radioactive implant, or radioactive device and that any such materials were removed prior o the execution of this
Authorization Form. Failure to remove these items prior to cremation may result in harm to the crematory and
clam�ry Personnel.
G'1{. INJe hereby affirm that instructions have been given to Paul M. Dietrich
regarding the removal of any personal property or other thing of value which any person signing below or an)'family
member of the deceased wishes to preserve. rwmeaN ram) Pine View Commissions is not
responsible fa removal of personal items from the container orfrom the remains of the deceased Personal Sams
Will In the container or with Me remains will be destroyed by the cremation process and cannot be retrieved
P}��1),emotion.
yam' IMe hereby authorize rwnwrx n.+w Pine View Crematorium tocrematethe
remains of the deceased.
FINAL DISPOSITION
The person authorized to receive the cremated remains of the deceased from the crematory is;
Name: Carlson Funeral Home, Inc.
More": 68 Main Street,Hudson Tells NY 12839 Phone: 518-7474243
The cremated remains of deceased will he disposed of as follows:
Burial at Gerald B H. Salomon Stratom National Cemetery
It for any reason the person named above does not take possession of the cremated remains,
Imnaun„s,,,,r Pine View Crematory is aulhoroad to give Possession of the remains to
rm.,e,nnamsnamu Carlson Funeral Home Inc. by delivery in person or by registered mail.
John F. HoRim, Sc
DOS-18BafJ(Rev. atllO) IYm>al0xeue0 pse2d3
pn=i rna rolroare)
understand that if the remains are not craimed within 120 days of cremation,
foe sear Pine View Crematorium may defines of the remains in an irretrievable manner,
sum as by scattering.
CREMATN)N CONTAINEWURN
pnNM l ONE of the rclomirid
An um to be used as a container for the cremated remains has been purchased from
Carleton Funeral Home Inc.. end is describedi as follows:
Ii understand that if the um is too small to hold the entire cremated remains, an additional rigid container may he
used for delivery.
-OR-
An um has not yet been purchased. li understand that if no um is purchased or otherwise provided
f mat Pine View Crematorium will place the cremated remains in a Wid temporary
container for tlelivery.
The Authorization Form was provided by (cmmiarexmrensl Paul M. Dietrich
was executed an emmni m wnn Carleton Funeral Home,Inc
(seem home.aenm) 68 Main Sti Hu ou Falls. NY 12839 and is signed by the natural director
as witness to or execution.
NNe have received a completed copy of this Am Onzztion Form.
The person(s) idenffed below islare the persu n(s) in control of disposition, who by signing this
Authorization Form, attest(s) to the accuracy and completeness of the information contained in this
Authorization Forms and auNorize(s) the foregolrg.
Slg this '3 � / dayof nnJ�. 'J 120 2�
Andreas
Ty,mlwP WNmre W'w'ae
Address
T11mtlp MMtl Nees �H
Address
WITNESS:
Paul M. Dletdch
rlmwel Db Tryeev FAMll xomrrszri
10946
aeae•sat eumae.
IoM F. Hopes, Sr.
DowlaeHi lnev.01n01 IwMw0e Popaaera