Dematties, Joseph Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745.4476
FUNERAL HOME: p"te lI'
-- 9�— RETURN TIME: _
DATE & TIME REMAINS ARRIVED AT CREMATORY; _ Q
lbl--m N �Ah
NAME OF FUNERAL DIRECTOR OR REGRISTERED RQSIOENT DELIVERING REMAINS:
NAME: ._ .__. _�S� METeS _ __ q
/l __�_CgSE p
TYPE OF CONTAINER:
Y_MdJt PLACE of DEATH: Vic
.,_4E6- �_f �2_.. i.M0,
ESTIMATED WEIGHT OF REMAINS & CONTAINER__ /� 71011
PLACED IN HOLD: �F
PLACED IN REFRIGERATION:
DATE OF CREMATION; _ _
TIME STARTED: ___ 7:hAT1 TIME COMPLETED: g170 Ah
PLACED IN RETORT: 7f)S,_—_ 4 Aau[rry
MOVED;
RETORT A IN WHICH REMAINS WERE CREMATED:
_ sGRit L4-yfl>m_._
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SHALL BE RETAIN" IN THE PERMANENT FILE OF THE CREMATORY.
Authonzation for Cremation and Disposition NY$Da°uwtaswo
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Date: 91I019 Number tm ldD
ommmory Name: Fine Yew Crematory
Adtlress: Quaker Road, Queensbury, New York 12804 Phone: filaTiil
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation is carried out by placing the remains of Me deceNled and Me container holding the remains into a
cremation chamberwherethey are subjected to intense beatandflame.The heat and flame will incinerate and
consume everything except bona and metal, which are all that will Is left after cremation.
Following cremation, Me crematory well lake reasonable efforts to remove an of the remains and other material ham
the cremation chamber, but some minimal dust and hall all It" be kit behind The crematory will separate
incidental and foreign material from the remains and the incidental and foreign material well be disposed of as
required by law. The cremated remains will be mechanically pulverwid into small pieces and placed Who a
designated container or urn. Changed remains generally are pulerizetl until no single fragment is recognizable
as skelefnl tissue.
OPENING OF CONTAINER
The crematory may only open the container holding the un-cremated human remains in limited circumstances, such
as M confirm the kengly of the deceased or to ensure that no material is enclosed which might injure employees or
damage crematory property. If human remains am delivered in a container which A not gotten for cremation
such As a ceremonial or parent casket, Me cremmory will require that the remains W 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 wnneas and will be done in privaq, who dignity and respect.
IDENTIFICATION OF DECEASED \ ,�/
Name of Deceased: Sa se SbnfU Ud/ 17IBT1/KS Madtalslaus, " IPA
Lam known Moral y8l 205d Qd Qibwaf lU».y n/ 1/ 12 .PO4
Place of DeatM1:
Sax: oM of Age: 0& DOB: 1 J3 if Data of Death: ply&as Estimated Weight 2CQM
Description of casket/conteinar in which remains Net the delivered:
Cormgated CardboaM Box with Plywood StamleA Model #3MB
PERSON IN CONTROL OF DISPOSILON
(Personnal in control of deposition sees ONE of the Weevi g)
1 are Wa are the designated agent of the deceased designated in a will or wniten instrument executed
pursuant to Public Hel Law section 4201.
-O__R- /
�L NAk have no knowledge that the derombed executed a written instrument pursuant to Public Heats Law
match 4201 or a will cerebral direCtimns for the it sposilian of ok or her remains and (CwOnuad nestp l
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I aM we are the person(s) Raving priority under Pudic Heats Law section 6201 and have the right autlndn
crematim Of the remains of Me deceased. 31ymur reationship In me Maxwell Is w li lwx:
(Inert fiorn lM IIG C&pxf
Number�Desaiption: 'k fhJ4 NSZ+-x-
A Person designated in wafting pursuant to Pudic Heats Law section 4201 (3);
2. The survrani; spouse;
L.The survivkg dom xacZarner;
years of age oroker
A A surviving Parent
S. A surviving sibling eighteen years of age or older;
S. A lawfully appointed guardian;
y. Any Persons)eighteen years of age or older entiMtl to share in Me estate and who same closest in
relationship to the deceased,
S. A duly appointed fidudary of the estate:
9.A close frtem or relative who has executed a written statement punivant to Public Health Law §4201(7);
10. A chief Racal officer of a county or a Public administrator appointed pursuant to the Sunogate's Court
Procedum Ad;
1Oa. Any other person who Is achrg on behalf of the deceased and who has executed a written statement
pursuant to Public Health Law§4201(7).
pgy LL THREEafhe mecvnrrgl
rr*/ lMe hereby Am Mat Me body of Me deceased does not contain a battery, battery peck, power cell,
radioactive implant, or radioactive device and that any such materials were removed prior to the execution of this
Authobzation Form Failure to remove mesa Items pdorto cmna0on may msuh in harm to me crematory and
crematory personnel.
ly, IANe hereby affirm Mat Instructions have been given to Mmrw'mreewnem l 3hn Baker #10159 regarding
the removal of any personal property or other thing of value which any person signing below or airy family member of Me
deceased wishes to preserve. (owrwf,men) P'neVew Cremarory is not responsible for
removal of personal items from the cenlener or from the remains of the deceased Personal Rem* Its in the container or
wit Me remains will be destroyed by We cmnation pmcaes and cannot be reldevad after cremation.
Me hereby authorize (,mwwy ,,x Piney Crematory to cremate the
remmne of the decemed.
FINAL DISPOSITION
The person authorized to receive Me cremated remains of Me Maxwell from Me crematory is:
Name. Baker Funeral Home Personnel
Address 11 Lativette Skeet 0ucensWry New Yoh 12306 Phone: (518)761-9303
The clameted remains of deceased will be disposed of as follows:
Return to family to Oe decided
If for any reason Me Person named above does not take possession of Me committed remains,
Ow"Geys+,w Pine View Cemaory is autorizetl to give possession of the remains to
(rvrxiellm'emmel Baker Funeral Home W deliveryT rr in Peon o^r by registered mail.
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��/ INJa mwersfantl MattlMe remains are nd GaimN whin 120 days of cramadon,
tuw.He,xmm� P're View Cremabn mry iispose of Me remains in an unremovable manner.
such as by scattering.
CREMATION COWAINEMRN
(lnNe ONEMdrehybwng)
An um M be used as a mntakier for our cram mul remains has been purchased from
Bayer Funeral Home and he described as follows:
IANe understand Mat if Me um Is too small M hold Me entire cremaletl remains, an additional rigid container may be used
for delivery.
-OR-
J_An um has not yet been purchased. VYJe understand Mat if no um is purchased or oNeiwise provided
(am* nsrrwl Pineviewcoarmatory will place Me aemetetl remains in a rigid temporary
containerfordalivery.
This Autionzation Form was provided by m wnv v�vrel � ti �NXXrn2
ecutetl at M�wwnmmnml Baker Funeral H
pumn�noireleeaasi if Lafevede Street 0ueensburv.New York 12e00 and is signed by has funeral director
as witness M its execution.
IANe have received a completed copy of Mis Authorization Form.
The peraonts) identified below Ross Me Weasels) In control of Melioration, who by signing the Automation
Fomr, Means)to Me accuracy and completeness of the Information combined In this AUMorization Form and
auMorize)s) Me foregoing.
Signed this 4 dayd 41"gx P— . 20�Q_.
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