Wear, Christopher Scott Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 Or (518) 745.4476
FUNERAL HOME: —POM,.... __
__ RETURN TIME: _ ADFE
DATE & TIME REMAINS ARRIVED AT CREMATORY: _ 7I1YI A 7' 3
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
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NAME:TYPE OF CONTAINER:
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PLACE OF DEgTX:
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ESTIMATED WEIGHT OF REMAINS & CONTAINER___
PLACED IN HOLD: am PN
PLACED IN REFRIGERATION: 11
DATE OF CREMATION: 7-7 7
TIME STARTED:
y TIME COMPLETED:PLACED IN RETORT: _ ___MOVED: � `q+!
RETORT Y IN WHICH REMAINS WERE CREMATED:
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN OB HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE;atSImnnoN LOG FHALL BE RETAINED IN THE PER IT FILE OF THE CREMATORY,
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Authorization for Cremation and Disposition en n wmw.lm
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This Amho SOM ((rom muatM comphesdandslgneal m delivery of materQia/l� for emission.
Dale: 717N Iba Number
Crematory Name: Pine View Crematory
Address: Quaker Road Oueensbury, New York 12804 Phone. f518)745-04]7
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation Is carried out by placing the remains of the placement and the container holding the remains into a
cremation chamber where they are subjected to intense heat and flame. The heat and Dame will incinerate and
consume everything except bone and more which are all that will be left after command".
Following cremation, the crematory will take reasonable shods to remove an of the remains and Other material from
the Cremation chamber but some minimal dust and hu idue 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 pal and placed into a
designated container or um. Cremated remains generally are pulverized until no single fragment m recognizable
as skeletal tlsaue.
OPENING OF CONTAINER
The crematory may only open the Container holding the un-cremated human remains in Ilmiled arcurnm ncea, such
as to confirm the ideMdy 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 m not Sob ble for Cremation
such as a ceremonial or rental casket,the crematory will require that the remains M moved into a suitable
container before If accepts the 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: pp r Mental Status.Masl
Lae Known Addrerrss: (� �7p nil II: .ylrmrn&il N4 I11543
Place of Death & YCDV` & C2 RS
Bill iqM of Age: 59 DOB 151.31 tghe oateof Death. I p Estimated VJeighc ��
Description of caakeVwntainer in which remains will be delivered
Corrugated Cardloard Box with Plywood Stannark Model a 38808
PERSON IN CONTROL OF DISPOSITION
(pure aJ in mritrd Ofdisposini Initial ONEofthe following)
1 and NM are the designated agent of the dearased designated In a will or murder instrument exeCMed
ruminant to Pudic Health Law m ion 4201,
-ORy1.-I
NAsa have no knowledge that the decimal ex,wde0 a written instrument pumuam to Public Heats Law
sec on 4201 or a will commining directions for the disposition Of his or her remains and (Cwfinuad nextreaa)
C Wear
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I ant we are the persons) M1aving priority under Public Health Lam,sa dlon 4201 and have the right to auMorice
cremation of the remains of Me tteceased stingier relationship M Me aebeesed is as follovn:
(Insert hour Me list below) r
Number: 2 (Cescription; W 14P.
A person designated In witting pursuant to Public HealM Law section 4201 (3);
G3. The surviving spouse',
L.The surviving domestic rafter;
3. Any surviving child eighteen years of age or older;
A A surviving parent;
5. A surviving sibling eighteen years of age or older,
9. A lawfully appointed guardian;
T. Any persons) eighteen years of age or older en thed M share In Me estffie and who livers closest In
relationship to the deceased',
8. A duly appointetl fiduclary of the estate,
9. A close MeM or relative who has executed a written statement pursuant to Public H03M Law §4201(7);
10. A chief fiscal officer of a county or a public administrator appointed pursuant to the Sunogate's Court
Procedure Act'.
1 Oa. Any other person who Is acting on behalf of Me deceased and who has executed a written statement
pursuant to Public Heats Law §e201(7).
(/pQjywLL THREE move following)
/^O IANe hereby affirm that the body "a decea does nth rain a battery, battery pack, power cell,
radioactive Implant, or radioactive device and that any such m were removed poor to the execution of this
Authorization Form. Failure to remove these dams prior to ommadon may result In harm to Me crematory and
crematory personnel.
}Q Wye hereby affirm that instructions have been givens (mirencrettwnemn Sfan Baker 810159 repaNing
Me removal of any personal property or other thing of value which any Person signing below or any family member of the
deceased wishes to preserve. ruemdey.emm Pine V'ev Crematory is not responsible for
removal of personal Rams from Me container or hom Me remains of Me deceased Personal items Its in the con amer or
with Me remains will be destroyed by the cremation process and cannot be rehleved after cremation.
s,N� Me hereby Mberiz¢I�.rono...i P'ne V'ew Crematory to cremate Me
remains of the deceased.
FINAL OISP0SITION
The Person authored to receive Me cremated remains of the deceased from Me crematory Is:
Name. Baker Formal Home Personnel
Address: 11 I aftivem,Street Queembury New V rk 128M Phone: (518) 761B 03
The cremated remains of deceased will be disposed of as follows'.
Return to family to be decided
If for any reason Me pemon named above does not take possession of Me cremated remains,
is aumonzed M give possession of the remains M
rniw.mom.o.m.1 N e F H by delivery in Personor by registered mail.
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eve _Me understand Nat Ifthe remains are nat claimed within 120 days M cremation,
rowwraynamal Pine Yew Crematory may dispose of the remains in an imemevable manner,
such as by scanning.
CREMATION CONTAINERIORN
In( itirl ONE of Me thlowing)
An urn to be used as a container for the cremated remains has been purchased from
Baker Funeral Home and is Marmload as follows:
Me understand Nat 0Me um Is too small to hold the entire cremated remains, an additional rgld container may be used
for delivery.
-OR��-\
— y _An um has not yet been purchased We understand Nat d no um is purchased or otherwise pmvlded
tm+wm�wmi_Pine Uew Crematory will place Me cremated remains In a rigid temporary
container for delivery.
This Authorization Form was provided by M�%+'arecmn.me
was executed at rr,'Vrw nwa,ai Baker Funeral Home
(�nw,eamssl it Y 1 and is signed by Me funeral director
as witness to its exeatlon.
IANe have received a completed! copy of Nls Authorization Form.
The person(s) identified below islare the panonla) in control of dispoaltlon, who by signing this Authorization
Form, al[estfs) to the accuracy and completeness of the Information contained In this Authorization Form and
authorize(s)the foregoing. TT
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Signed this dayof Ju1V . 20 DO
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