Packard, Samuel Richard Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745.4476
FUNERAL HOME:
- _. . _ RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY:
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
___ HW
NAME: %SAND L PA( RD __' LASE R gl�_
TYPE OF CONTAINER: ,y "&Dr 11 ,, - / (/y�F,.p( A Ap� b�
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PLACE OF DEATH; _ 16 �iU M �
ESTIMATED WEIGHT OF REMAINS & CONTAINER ao dr L?k
PLACED IN HOLD:
PLACED IN REFRIGERATION: ZOK JTI
DATE OF CREMATION: -?In ItD
TIME STARTED: -R7R'q)-i TIME COMPLETED: C1mll
PLACED IN RETORT: _ �/'YA� MOVED:
RETORT N IN WHICH REMAINS WERE CREMATED: 6.1_LNI(
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 Cremati6n and Disposition "';'Deputies If
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This AuNorization Form must his completadaM algmdprlorto dNhrery of manages for ce awn.
Date: 07/16/2020 Number 421
Crematory Name: Pine View Crematorium (( ..
Address'. Quaker Road tneemb NY 12804 Phone: Eg -q
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation is carded out by placing the remains of the deceased and the container holding the remains ireo a
cremation chamber where they are subjected to intense heat and flame. The heat and flame will incinerate and
consume everything except bone and metal, which are all that will he left attar cremation.
Following cremation, the crematory will take reasonable eflorta to remove all of the remains and other material from
the cremation chamber but some minimal dust and residue will likely he 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 remains generally are pulverized until no single fragment is
recognizable as skeletal tissue.
OPENING OF CONTAINER.
The crematory may only open the container holding the un-cremated human remains in limited onaimstances, 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 ceremonial or rental casket, the crematory will require that the remains he moved Into a suitable
container before it 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 dignify and respect.
IDENTIFICATION OF DECEASED
Name of Deceased Samuel Richard Pickard Mental Status: Married
Lose Known Address: 3528 Burporyne Ave., Hudson Fars,New York 12839
Place of Death: Diane Falls Hospital,Glens Falls New York 12801
SeI& F Age: 75 DOS: 1014/19" Detect Death: 07/14/2020 Estimated Nleig 21¢61hc
Description of caskedcoramner in which remains will be delivered Madl2ews Cremation Case
Cardboard mp/plywood twttom
PERSON IN CONTROL OF DISPOSITION
(Perko fflu in coif of destruction, mfial ONE of the fodowing)
_ I am/\Ne are the designated agerd of the deceased designated in a will crwriden instrument executed
pursuant to Public Health Law section 4201.
-OR-
I�p_ Wfee have no knowledge that the deceased executed a written instrument pursuant W Public Health law
sedum 4201 or a will containing directions for the disposition of his or her remains and (emedued rn.roasm
Samuel Richard Packard
oo It (Rut mnp) w.m.woea.wd s.s.t ua
�I aM we are Me parsons) having prionty under Public Health Law section 4201 and have the right to authorize
cremationofiheremainsofthedecessed. MyfOurralationshipto the deceased is esfollows:
(Insert rom Me list below)
Number: 2 Description: wife
1. A person designated in writing pursuant to Public Health Law section 4201(3);
2. The surviving spouse;
2a. The surviving domestic partner,
3. Any surviving child eighteen years of age or alder,
4. A surviving parent:
S.A surviving sibling eighteen years of age or older:
6. A lawfully appointed guardian;
T. Any pamon(s) eighteen years of age or older emitted to share In the estate and who islare 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 pursuers to Public Health Law §4201(7);
10.A chief fiscal officer of a county or a public a imimistrator appointed pursuant to the Sunomm's Court
Procedure Act;
10a. Any other person wh0 is acting on behalf of the deceased and who has executed a written statement
pursuant to Public Health Law §4201(7)
(Initialf ALL THREE oftbe heirg)
C 1 lMe hereby affirm that the body of the deceased does not contain a battery, battery, pack, power call,
radioactive implant, or Radioactive device and that any such materials were removed prior to the execution of this
Authorization Form. Failure to remove theme items prior to cremation may result in harm to the crematory and
crempaory, personnel.
01 ( li y hereby affirm that instructions have been given to M,,w'en u,mw,) Cassandra S. Maine
regarding the 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 rcv,,mc ne+el Pine View Crematorium is not
responsible for removal of personal items from the contairrer or from the remains of the deceased. Personal Items
left in the container or with the remains will be destroyed by the cremation process and cannot be retrieved
Mar cremation.
Ii hereby authorize Pine View Crematorium to cremate the
remains of the deceased.
FINAL DISPOSITION
The parson authorized to receive Me cremated remains W the deceased from the crematory In:
Name: Carleton Funeral Home Inc.
Acidness 68 Main Strat Hudson Falls NY 12839 Phone: 518-7474243
Tha cremated remains of deceased will be disposed of as fntlaws:
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If for any reason the person named aL atloas rat take possession cremated remains,
lmm.mnnemml Pine View Cretman s authorized to give possession of the remains to
pwem 'i noun Carlecon Funeral Ho Inc by delivery in person or by registered mail.
garment Richard Packmd
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61 INJe understand that Ripe remains are not claimed within 120 days of cremation,
r';M—y'amo Pine View Crematorium may dispose of Me remains in an irretrievable manner,
such as by scattering.
ONENATION CONTAINERNRN
(In=el ONE of Me falbvmq)
An um W be used as a container for the cremated remains has been purchased from
Cadence Funeral Home. Inc.. and is described as Whims:
IM'e untleratend that R tM1e um is too small to M1old the entire aematetl remains, an additional rigid container may b s
used for delivery.
VAn um has not yet been purchased. IANs understand that if no urn is purchased or otherwise provided
)cwrwftvf e) Pine View Crematorium will place the cremated remains in a rigid temporary
container for delivery.
The Authorization Form was provided by Mviwal moan O Cassendm S.Mtille ,
was executed 9 punym narw) Carleton Funeral Homo Inc.
Mianimmremrwl 68 Main Street, Had son Falls,NY 12839 and is signed by the funeral director
as whness to its execution.
INde have received a completed copy of this Authorization Fpnn.
The person(s) Identified below islare the person(s) in control of disposition, who by signing this
AUMorizafion Form, afteat(s) to the accuracy and completemsa of Me information contained in this
Authorization Form and autho iize(s) the foregoing.
Signed this L day of July
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WITNESS:
Cassandra S. Mai11e
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Samuel Ricbmd Packard
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