Bolster, Joyce Bolton Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: '-�-I4/ _ _ __ _ RETURN TIME: /10ry�e
DATE 8 TIME REMAINS ARRIVED AT CREMATORY:
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAIN$:
5 14�o
CABF p
TYRE OF CONTAINER: _Ofc!!V AS ///�I� �}/A.
PLACE OF DEATH: I �oOf It
ESTIMATED WEIGHT OF REMAINS B CONTAINER_ /4d
PLACED IN HOLD:
PLACED IN REFRIGERATION: _
DATE OF CREMATION: 7'Z7- qp yO
TIME STARTED: /SOS MI TIME COMPLETED:
PLACED IN RETORT: I/OS tfh /
RETORT C IN WHICH REMAINS WERE CREMATED: Sw�' &d )G
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 08 HOURS
FROM TIME OF ACCEPTED DELIVERY: L
NOTE THE CREMATION ON LOS SHALL BE RETAINED1N THE PERMANENT FILE OF THE CREMATORY.
Nys meaweem 0 sure
"Authorization for Cremation and Disposition Onae� ,,,,,, a'w.iioNUY*0i nAYviiiis
"any NY IRJI
(518)94kGZ*
..wrdo..m u:
Nepal
This Authorization Form must" compieRU and signodpdwto delivery of remains for demotion.
Dace: 7-m7-WQ Number: k7
Crematory Name: V' G
Address' Ouaker Read, pueenstrury, New York 12804 Phone: (5115745-4477
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation is earned out by placing the remains of Me deceased and Me container holding the remains Into a
cremation chamber where may are subjected to intense heat and flame,The heat and flame will NicholaM and
consume everything except More anti metal,which are all Net will be Taft after cremation.
Following cremation, the crematory will take reasonable efforts to remove an of the remains and other material from
the ttematlon chamber, but some minimal dust and rescue will likely be out behind The crematory will separate
incidental and foreign material from the remains and the madame) and foreign material will be contest of as
required by law. The cremated remains will be mechanically pulverized imo small places and plated Into a
designated container or urn. Cremated remains generally are pulverized until no single fragment is recognizable
as skeletal tissue.
OPENING OF CONTAINER
The crematory may only open the consumer holding the un-cremated human remains in limited circumstances, such
as to confirm the identify of the Deceased or to ensure that no material is enclosed which ri 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 be moved into a suitable
container Wore 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 dignity and respect.
DENTIFICATION OF
(Name d Deceased. ETEA �'� SJ.. l 1
-;Cl 11 (� � /, / I I �T '1 Madlal Statuses LfaOUQd
Last l(nown Addre^es. 1a I rk VC and NU % ugoi 4 llIS w �\1<p% O �
Place of Death: d ryukl�CA A �V I S 115 tvl I O' 0ot
Sex: oM OF Age: SCl DOB,N/p2 � 7S'il Deledoeam:Tpryt .D Esdmaledvelghc I (7tSg
Description of casketlwntainer in which remains will be delivered:
Corrugated Cardboard Sox with Plywood Starmark Model a 3880e
PERSON IN CONTROL OF DISPOSITION
(oonedi(s)in owned ddsposmon. initial ONE of me Mbol
I all Vie are the designated agent d the deceased designated In a will or written instrument executed
pursuant to Public Health Law section 4201.
-OR-
ftK have no knowledge that(he recessed executed a wrden instrument pursuant to Public Heats Low
section 4201 or will containing directions for the deposition of his or rim remains and (Cont(nued nexterse)
p .laWf.[ (Rer. 12n1) Nmn PyetdJ
I anni are the psharns) having pdomyt under Public Health Law section 4201 and have the right to authorize
cremation dthe remains ofthe deceased. all Relationship to Me deceased lo as highest:
Imsed from the fist Ocbw) n f�
Number--j—Descriidon:
A person designated in writing pureuan Public Health Law,section 4201 (3);
2. The surviving Moves,,
2C.The suNNing domestic padrren
Q3. Any surviving child eighteen years of age or older;
4. A surviving parent
S. A summing 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 share closest in
relationship to the deceased)
S.A duly appointed fiduciary of the estate,
S.A close Mend or relative who has executed a written statement pursuant to Public Health Law§4201(7);
10. A chief fiscal officer of a county or a public administrator appointed pursuant the Suncgate'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 Heald Law §4201(7).
(lpgja(ALL THREE a the following)
�- Inge hereby affirm that the hotly "a decea does not t a baftery, aery pack, power cell,
radioactive Implant. or radioactive device and that any such m� S_ae^ evW pror to the execution of this
Authorization Farm. Failure W remove these items prior to cremation may rail In harm td Me crematory and
crematory DjgrL NAh hereby affirm that instructions have been given W 1015g regardingd
the removal of any personal property or other Ming of value which any person signing below or any family member of the
deceased wishes to preserve. (u.mamxneme Fruylexcreml is not responsible for
removal of personal items horn Me container or from the remains of the deceased. Personal items loft in the container or
with the remains will he dMmyed by the cmmafipn process and cannot be Ransil Char cremtlbn.
..�- IlWe hereby authndxa fvmelµ16.m,__Phke V C to chadl the
remains of the deceased.
F NAL DISPOSITION
The person authorized to receive the cremated remains of the deceased from Me crematory is.
Name'. Baker Funeral H —
Address. 11 Lae Ended DuesinsdayNew York 12M Phone: 51m T6Lg3N
The cremated remains of deceased will be disposed of as follows:
Return to family to be decided
If for any reason Me person named above does not take possession of the cremated remains.
Iommwr�w�.1 P' V G is mad m
o sad to give possession &Me reains to
earverws, sal B k F I. IH bydelivery in person or by registered mall.
R �
oos.teesutn.,.mrrdt w,»a ew.z°"
GdPIgIlhe Io'row„�
IANe understand that If the remains are not clai ned within 120 days of cremation,
may dispose of the remains in an inebmwabe manna,
such as by scattering.
CREMATION CONTAINERAIRN
(Inn alONEoftM ANOWiig)
An um to be used as a container for the cremated remains has been purchased from
Bayer Funeral Home and Is described as follows'.
IANe understand Nat IMe um is too small N hold de entire cremated remains, an additional rigid container may be used
for delivery.
-OR-
4 A�An um has not yet been purchased. IANe understand Nat N no um is purchased or otherwise provided
Io.mwon,w,,.I P' C will place Me cremated remains in a rigid temporary
container for canary.
This Authorization Form was provided by llw..a6Nunemel
was executed at�narrn) B k F H
pwwninw..aeress, ttl =f=cane SVeel Oueenaburv-New Yark 12B04 and is signed by the funeral director
as witness to ga execution.
lame have raceried a completed copy of this Authorization Form.
The personal Identified below Ware the parson(s) In control of disposition, who by signing this Authorization
Form, attests) to the accuracy and completeness of the Information contained in this Authorization Form and
authoraets)Me foregoing.
Signed thl. a day of U1 rag .
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Funeral Home Reg. M1130
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