Hill, James Wesley (2) Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12864
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: ..4rL
---- ___ ., RETURN TIME: ///ham
DATE 8 TIME REMAINS ARRIVED AT CREMATORY:
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIOINT DELIVERING REMAINS:
NAME: ..__:10+41
TYPE OF CONTAINER:
PLACE OF DEATH;
ESTIMATED WEIGHT OF REMAINS 8 CONTAINER__
PLACED IN HOLD:
PLACES IN REFRIGERATION:
DATE OF CREMATION: _
7• 3/ 7o2N
TIME STARTED: , I0 SOAT'1 __TIME COMPLET¢O: ^I Z� S�f�.
PLACED IN RETORT:
RETORT 9 IN WHICH REMAINS WERE CREMATED: Jn'X�_POy�i rSk
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN qB HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SMALL BE RETAINED IN THE PERMANENT FILE OF THE NE CREMATORY
Authdnzation for Cremation and Disposition "°o ow ofce 6;.`
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Data 07/30/2020 Number: y
Crematory Name: Pine View Crematorium
Address. Quaker Road Queensbury NY 128N Phone: 41874l
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation is earned out by placing the remains of the damaged and the container holding the remains into a
cremation chamber where they are subjected to intense heat and flame. The heat and flame will incinerats and
consume everything except bona and metal, which are all that will be left after cremation.
Following central the crematory will take reasonable efforts to remove all of the remains and other material Them
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 purserized into small pieces and placed into a
designated container or urn: Cremated remains generally are pulverized until no single Mgment is
recognizable as skeletal flssue.
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 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 be mwatl 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 Normal and will be done in privacy, with dignity and respect.
IDENTIFICATION OF DECEASED
Name of Deceased: James Wesley Hill Mantas Status: Never Married
Last Known Address: 47 Old Mill Lane Queensbury NV 1281M
Placeo��f D�eath: 47 Old Mill Lane (rxdmm bury NY 12804
SipL� / F Age: 96 DOB'. 04R0/1924 Dateaf Death: 07/30/2020 EstimatWVdeighb Ipfb
Description of caskeUcontsiner in which remains will be delivered: Maz0¢ws Cravation Case
Cardboard top/plywood bottom
PERSON IN CONTROL OF DISPOSITION
(Peroon(a)in Gunter(m dfareat initial ONE of the reggaes g)
I am/ We are the designated agent of the deceased designated in a will or written instrument executed
pursuant to Public Health Law section 4201.
OR-
I/We have no knowledge that the deceased executed a written instrument pursuant to Public Health Law
ctryH201 or a will containing directions for the disposition of his or her remains and (conunuee marriage)
James Wesley Hill
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I'apd wd are Oe Perron(s) having priority under Public Health Law section 4201 and have the right to authorize
cremation of the remains of the deceased. MylOur relationship to fine tlxsased Is as follows:
(Insert from the list below)
Number'. T Description: friend
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 older;
4. A surviving parent:
S. A surviving sibling eighteen years of age or older:
S. A lawfully appointed guardian;
T. Any person(s) eighteen years of age or older emitted to share in the estate and who Was closest in
relationship to the deceased,
S. A duly appointed fiduciary of the estate;
9. A dose friend 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 to the Surrogale's Court
Procedure Ach
a. Any other person who is acting on behalf of the downed and who has executed a written statement
ursuant to Public Hart Law §4201(7)
g(I - LL THREE of the (allowing)
Me hereby affirm that the body of the deceased does not contain a batery, battery pack, Power cell,
Ive implant, or radioactive device and that any such materials were removed prior to the execution of this
Authorization Form. Failure to remove these Items patch to cremation may result In harm to the crematory and
monnel.
e11/I hereby affirm that instructions have been given to pw.y dv=rmm l Paul M. Dietrich
raga 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 rm, uvy....i Pine 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 cremation process and cannot be removed
m on.
(vr" a hereby authorize rmm ni Pine View Crematorium to cremate the
re of the deceased.
FINAL DISPOSITION
The Parson i umonzed to receive the cremated remains of me deceased from the crematory is:
Name: Carleton Funeral Home Inc.
Address: 68 Main Street Hudson Falls NY 12839 Phone: 518-7474243
The cremated remains of deceased will be disposed of as follows:
Burial in Kinston, NC
If for any reason to person named above does not take pomassion of the cremated remains,
Imm.mn�mw Pine View Crematory is authorized to give possession of the remains to
Carleton Funeral Home, Inc. by delivery in person or by registered mail.
James wesle Hill
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(Lai me hlrowing)
41 MANe understand that if the remains are not claimed within 120 days of cremation,
me) Pine View Crematorium may dispose of the remains in an irretrievable manner,
such as by scattering.
CREMATION CONTRINERNRN
(Initial ONE of the bllawirgf
um to be used as a container for the cremated remains has been purchased from
als�cwleton Funeral Home Inc.. apd is described as follows:
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lMe understand that it the urniis too small to hold the entire cremated remains, an additional rigid container may be
used for delivery.
-OR-
An urn has not yet been purchased. We understand that if no um is purchasetl or otherwise provided
Imemai Pine View Crematorium will place the cremated remains in a rigid temporsry
container for delivery.
The Authorization Form was provided by tluverw elxlwrwmd Paul M. Dietrich
was executed at pwwmnw+xmmel Carleton Funeral Home Inc.
Immmm hi ecemq 68 Main Street Hudson Falls NY 12839 and is signed by the funeral director
as witness to its execution.
lMe have received a completed copy of this Authorization Form.
The persoms) identified below isJare the prsonls) in control of disposition, who by signing this
Authorization Form, alai W the accuracy and completeness of the information contained in this
Authorization come and authorize(s) the foregoing.
Signadthis 30 day of July , 20 20 .
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NATNESS:
Paul M. Dietich V'rnX VVt O
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James Wesley Hill
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