Horineck, Marion M (2) Pine View Cemetery g Crematorium
Quaker Road
Queensburyl NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: -rAR � _
RETURN TIME:
DATE B TIME REMAINS ARRIVED AT CREMATORY: _.__. $).3hN
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
PAu<
NAME; iJ IJ[ K GY�
- -
.. —1✓11[LC__._ /1 J� _LASER 811,
TYPE OF CONTAINER: MfNdy=__tSRIMEI 11N, nl .. -../ I II `—
PLACE OF DEATH:
ESTIMATED WEIGHT OF REMAINS R CONTAINER_
PLACEDIN HOLD:
PLACED IN REFRIGERATIONI __
DATE OF CREMATION: _
TIME STARTED! ___t_TIME COMPLETED:
PLACED IN RETORT: :GmAM
SA MOVED: __ I� yf )Il)p
RETORT IXIN WHICH REMAINS WERE CREMATED: __
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 88 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CARNATION LOG SHALL Be RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
Authorization for Cremation and Disposition "`09aon of comaives
One cwnmmre Pm, va Washington Means
marvata231
isl 226
..,.w.On Sta..ar.+
This Arrthpdzegon Form must be compleWandsignedpdozWd ivory of"al lnnna forcrematlon.
Data Vrl]2020 Number: gl0
Crematory Name: Pine View CrcmaWdum
Morass: QualkerRoarLiQueandfurryi,NY12904 Phone: CR9 Fai
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 heal and game. The beat and flame will incinerate and
consume everything except bone and metal, which are all that will be left attar cremation.
Following cremation, the rremMory will Wks reasonable efl0rts to remove all of the remains and Other material "an
the cremation chamber, but some minimal dust and residue will likely but aft 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 placetl into a
designated container or um; Cremabd remains generally am pulverized until no single fragment Is
recognizable as skeletal gssue.
OPENING OF CONTAINER.
The crematory may only open the container holding the un-cremated human remains in limited circumstances, such
as to confirm the identity of the deceased or to ensure that no materiel is encloa ed 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 Nat the remains be moved Into a suitable
container before it accepts the remains. The opening of a container or the transfer or removal N remains will be
conducted before a witness and will be done in privacy, with dignity and respect.
IDENTIFICATION OF DECEASED
Name of Deceased. NancyE Keefe Martel Status: Married
Last Known Address: 47 B W and Ap S Q bury N Y 2k 12804
Place of/D�ltO\ Glens Falls Hoe W Glers polls New York 12801
Sex: M 1 F J Age: 60 DOB: 01/09/1960 Date of Death: 0 7/3 01202 0 Estimated Weight Whirs
Description"offccaskeVcantainer in which remains will W delivered: Matthews Cremation Wsc
Cardboard top/plywood bottom
PERSON IN CONTROL OF DISPOSITION
(Person(sJ In consul of carrot trig@ ONE of Me touris )
_ I am/We are the designated agent of the deceased designated in a will or written instrument executed
pursuant to Public Heath Law section 4201.
-ORte—
I to I IMIe have no knowledge that the deceased executed a written instrument pursuant to Public Health Law
section 4201 or a will containing directions for the disix s@on of his or her remains and (cmtinued mar mae)
Not E. Keefe
Dos.l nea.r.l lee..oltlal Name doweat Page 1 03
I andive are the person(s) having prlodty under Public Health Law section 4201 and have the right to authorize
cremationoftheremainsofthedeceased. My/Our relationshlpto the deceased Is " follows:
(Insert firm the list below) /
Number: _2 Oascriptio . ^n: b :..:.+lS
1. A person designated in writing pursuant to Public Health Lew section 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:
S. A surviving sibling eighteen years of age or older;
6. A lawfully appointed guardian,
T. Any persons) eighteen years of age or older entitled to share in the estate and who rude 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 Law §4201(7);
10. A chief fiscal after of a county or a public administrator appointed pursuant to the Surrogate court
Procedure AM;
U 10a.Any other person who is acting on behalf of the deceased and who has executed a written statement
,*dam pursuant to Public Heats Law §4201(7)
a(InQ II pLL THREE of Me Id;oMw)
�"�' lMe 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 to the execution of this
Authorization Form. Failure to remove these items prior to cremation may result in harm to the crematory and
comatory personnel.
C— Innis hereby affirm that inunichons have been given to polowe n,wne Paul M. Dietrich
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. sv,,m ,.mat Pme View Crematorium Is not
responsible for removal of personal items from the container or from the remains of the deceased Personal items
left in the container or with the remains will be destroyed by the cremated prow" and cannot be rental
alter cremation.
$_ IMe hereby authorize rhoewmry�e) Pine View Crematorium to cremate the
remains of the deceased.
FINAL DISPOSITION
The Person authorized to receive the cremated remains of the deceased from the crematory is:
Name: Carleton Funeral Home Inc.
Address: 68 Main Street, Hudson Fall NY 12839 Phone: 51&7474243
The cremated remains of deceased will be disposed of as follows:
If for any reason the person nametl above tloes not take p"s"stoat of the cremated remains,
Immewn�am.l Pine View Crematory is authorized to give possession of the remains to
rrmwwno.,�.asm.) Carleton Federal Home Inc. by delivery in Person or by registered mail.
Nanc E Kcefe
005-1e9e4.1(na..amo) "'^'aaoiveenl pipe l al]
fm}v a fmmwmgl
/We understand that tithe remains are not claimed within 120 days of cremation,
ImmemyIwx P' Vim Crem ium ator may dispose of the remains in an irretrievable manner,
such as by scattering.
CREMATION CONTAINERNRN
dre0 ONE of the Idrowmm
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:
IWis understand that if the um is too small to hold the entire cremated remains, an additional had coMalner may be
used for del'wery.
O
An um has nth yet bean pumhaeetl. INJe understand that if place
um Is mated remains
or otherwise provided
p.m.wxnewel Pine View Crematorium will place the cremated remains In a rigid temporary
cononnerfordelivery. II '
The Authorization Form was provided by pummar.=m.mme) M 7 hack
was executed at pmmmhmi xi Carleton Funeral Home. Inc.
numral Bonn am"') 68 Main Sheet. Hudson Falk,NY 12839 and is signed by the funeral director
as witness to its execution.
IfAm have received a completed copy of this Autlmnzation Form.
The personals) Identified below isfare the person(s) in control of disposition, who by signing this
Authorization Form, attasgsl to the accuracy and completeness of the information contained in this
Authorization Form and authorizele) the foregoing.
Signed this 2"d day of August 3e 20 .
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Address
WITNESS: / v
PaW M. Dietrich
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10946
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