Winchip, Mary Lou Pine View Cemetery 8. Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4478
FUNERAL HOME:
----- ---___... RETU0.N TIME:
DATE BTIME REMAINS ARRIVED AT CREMATORY: - A (L (�L NAME OF FUNERAL DIRECTOR OR REGRISTEREO RESIDENT DELIVERING REMAINS:
NAME: _--.11C_AYS.-_.-___
1 /I CASEp _ sag
TYPE OF CONTAINER:
JYL I[ N,�7 ♦ 3izoP
PLACE OF OEgTN: .
ESTIMATED WEIGHT OF REMAINS 8 CONTAINER
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION: —{ #
TIME STgRTFO; __ ___�/.wan TIME COMPLETED:PLACED IN RETORT: ')_Sq
�_MOV O: j,fiq9M RETORT 4 IN WHICH REMAINS WERE CREMATED: _ II
�j ��(-� — ' I DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS �D'M:nII
FROM TIME OF ACCEPTED DELIVERY: 'MF I
NOTE: THE CREMATION LOG SMALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
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Authorization for Cremation and Disposition
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They Aumgrba8on Fisher mart be completed and signedIs1fw to deliveryofremains Ww "on.
Data 910to Number. Fie
Crematory Name' Pine yaav Cranahry
Address: Quaker Rosa Dromedary. NY 128041 Phone: (518)745 n
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation is wined out by plating the remains of the deceased and the container holding the remains Into a
cremation chamber where they are subjected to intense heat and flame. The beat and flame will Incinerate and
everything except bone and marl, which are all that will be left after cremation.
Followiang cremation, the crematory will take reasonable alit o remove all of the remains and other mamrial lmm
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 m rc mmica ly pulverized into mall pieces and placed into a
designated container or um. Cremated remains generally are pulverized until no single fragment is
recognizable as sWe lthese.
OPENING OF CONTAINER
The crematory may only open the conainer holding fire uncremated human remains in limited circumstances, such
as to confirm the identity of the deceased or to ensure that no mMenal is enclosed which might injure employees or
damage crematory property. R human remains are delivered in a container which In not suitable for cremation
such as a ceremonial or rental casket, the crematory wall require that the remains he moved into a suitable
container before it accepts the remains. The opening of a container or the transhv or removal of remains will be
conducted before a worries and will be done in privacy, with dignity and respect.
IDENTIFICATION OF DECEASED
Name of Deceased: M//A11 Rq -L �11 Ih\C HIP -� McMei Status:
Last Nnown Adtlress' / rl I a Vos a A7F \,- ` ! car IflibN ku1 ned
Place of beam: r t Gh\S h1 S H(� ITAL f-"I
sai Agi DOB: Ioamof Dean: H141y1] 58malea WalphC
FL—
Description of raskWconminer In which remains willthe
`delivered ��TT
41rr f4Q n t6a0 & -v6t. Poll l it —syylg
PERSON IN CONTROL OF 12IS62 OR
(PrOurde)w control ofdrepawtian, in"ONE oftM IdbMrq)
am/vve are the central agent of the deceased designaW In a will or wMtsn instrument execuhe
uaM to Public Health Law section 4201.
post have no knowledge that the deceased executed a written instrument women to Public Heats Lew
on 4201 or a will containing directions for the disposition of his or her remains and (fmaneed red pale)
Nl wlc.\rHIP
ms 1, at" 121,y mmad0oem0 e.ae, atr
I anvwe are Me person(s) having priority under Public Hall Law section 420f and haye Me rigMfo auMwze
aemation mme remalm of the deceased. MylOur relationship to me deceased b ae follow:
forest fiom Me list bri
Numbed oescripliom
1.A person designated in writing national M Pudic Heats .as;section 42a1(8);
2 The surviving spouse.
. The su 'Opadde ,
1. Any survivlrg Mild eighteen yew of age car
2 Asvmwn parent.
S. A surviving sibling eighteen years of age ar older.
6. A lawfully appointed guardian;
y. Any person(s) eighteen years of age or oiler entitled to share in the estate and who issue closest in
relationship to the deceased;
I. A duly appointed fidudary of the estate;
9. A close fiend or relative who has executed a written statement pursuant te Public Hai Law §QMl(7),
10. A chieffhoo l officer of a county or a public administrator appointed pursuant M the Suo0gate's Court
Prore0ure Act,
10a. Any other person who is acting on behaM of the deceased and who has executed a wdtfen statement
pursuant to Public Heats Law §4201(7).
Il. THREEofy ffinn rat
ri
LVJe hereby earth mat Me hotly n the tlec y sue mat not contain a battery, battery pack, power apt.
reds rve implant, or radioactive device and mat any such materials were removed prior to Me execution of Nis
Authorization Fdr. Failure to remove these items prior to cremation may result in harm to Me crematory and
pl;hkaborit personnel.
pyve hereby affirm that instructions have bean given to mw wnroemv l Stan Baker 1910159
hang the removal of any personal property or other Ming of value which any person signing below or any family
member of Me tleseasetl wishes to preserve. la.m.myiw.l Pine Vies C,emaxi is
not
responsible for removal of selected dams from me container or"in Me remains of the decreased Porsonalhems
left in Me container or with the remains will b s destroyed by the crema0on process and cannot be retrieved
, remns.
@ye hereby authorize (oevwceiw�+l Pine Viex Crematory to cremate Me
efts of the deceased.
FINAL o18POSITION
The person aumorimil to receive Me cremated remains of Me decased from the uematory is:
Name. Baker Fupeml Home
AtlMess:t1 LafaYede Sheet oueensbury NY 1280a Phone: (5187 i81-9303
The cremated remains of demos ed will be disposed of as follows.
Pt--ty ✓ fo vol
H for any reason the person named above dope not take possession of Me mematee remains,
(oennmemmw Pine Vies Cremetay isadm,lxed to give possession of the remains to
laawsneee,wnl Baker Funeral Home by delivery in person or by registered mail.
ma,ma.0 m« s,n% rare«IbaW Ppkas
gatiMlt ronarn�
ANe understand that ifthe remains are not claimed within 120 days of cremation,
(m s re..) Pine view Cremamry may dispose of the remains in an Irtmi ievade manner,
such asby scattering.
CeRFMATION CONTAINEIfURN
(L ME of Me/drowns)
An um to ba used as a container for the cremated remains has been purchased 1mm
Baker Funeral Home and is described as follows:
ItYm understand that if this an is too small to hold the more cremated remains. an additional ngld container may he
used for delivery.
O
An um has not yet bean purchased. If Am understand net if no um a purchased! or otherwise provided
r �wnar Pine Yew Cremabry will plane the cremated remains in a rigid temporary
for convert.
The Authorization Form was provided by finnere enexv amr Start Baker LFD#10159
we executed ai Mriarw horn.mew Baker Funeral Home
moan no�ids cur 11 Lafayette Street Oueensbury, NV 12904 and is dined by no funeral director
as orders to its execution.
lMe have received a completed copy of this Authorization Form.
The person(s) Identified below afem the person(s) in control of disposition, "a by signing this
Authorization Form, Moodie) to the accuracy, and completeness of the Information contained in this
Authorization Form and authonze(s) no foregoing.
signed the day of
� m - Mamie W��T i,ip d�..U,u,�k+:L�p- l.t7W1�
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WRNMS:
Stan Baker LFD#101%
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Funeral Home Reg.N11M
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