Guuett, Glen Samuel Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 Or (518) 745.4476
FUNERAL ROME: .
-fAy"i- ----.._—. _ _ _. RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: ,, ._. _ tin q,w
NAME OF FUNERAL DIRECTOR OR REGRISTEREO RESIDENT DAL-Lb IVERINO REMAINS-
NAME: ASS)
•� •••JL CASE N _
TYPE OF CONTAINER: ,E�
PLACE OF DEATH:
ESTIMATED WEIGHT OF REMAINS & CONTAINER _ Df ) --
PLACED IN HOLD:
--
PLALfO IN REFRIGERATION:
DATE OF CREMATION:
TIME STARTED: _ COMPLETED: IJSOPI'I
PLACED IN RETORT: LI L M
WE RETORT p IN WHICH REMAINS WERE CREMATED: !y (t
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SHALL eE n[TYpEO IN THE PERMANENT FILE Or THE c ER MATO
Authorization for Cremation and Disposition m..maau.a
me Cori n..a. .N.Im"..w
This ArMmie m Form Rrrat Ba corrlpl arMaignelpflor M daiivaryof remavu rpruamatlpn.
Data: Slnitg Number- QL9
Cremmory Name'. Pine View Crematory
Addreea: Quaker Road, Queenabury, New Yo* 12SU Phone: 51817454477
QEMATION IS AN IRREVERSIBIE AND FINAL PROCESS.
Cremation is Carried out by placing the remains of the deceased and the container holding the remains into a
cremation chamberwherethey are subjectedto intense heatand flame.have hW and Forms will lrldn"e ant wmume
everything mead bone am mural,which are all that will W left after Consumer.
Following the major, the crematory will Wks reasonable also as to remove an of the remalns and other material horn the
cremation chamber, but some minimal dust and residue will likely be left behind. The crematory will separate Incidental eM
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 placed into a designated Container or urn. Crcm
remains;generally are Wlvedaed wall no single fragment Is recognizable as skelHY flssue.
OPENING OF CONTAINER
The crematory may only open the container holding the un-cremated human remains In limited circumstances, such as to
onfrm the identify 0f the deceased or to ensure that no material Is enclosed wh c h might Injure employees or damage
atary propeay. if human remainsare delWered in a containerwhich A Art sultableforcremation such as accessional of
rentalrx ,Meaematwywlll r"ulte MattMremalnsWmovediMoamkable Container Belpreftadepts Me 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.
IDENTIFICATION OF DEE`CMEDC (� � 1�
Name of Oky ea sd1: ` � }r"1 1PY yG Vy`C[r�R� (� Mamal Btarm Jeri YEA
Last Known Atldreea: 4b3 D,ei7p,C 1lArM nary TpynS%S �4 \'J��({
II nn1 ``11 � In1 �
Place of Death: G DNS R IS till r o�TY
Nice OM of Al ooao�,/Cg/15411 Dareor oemn:��pgl�yo Emimate igm: `--T516s
Description of casket/comainer in which remains will be delivered.
Corrugated Cardboard Box withPlywood 5 rmrk Model a 388O8
PERSON IN CONTROL OF DISPOSITION
(Person n in control of disposition, initial ONE of the following)
I am/We are the designated agent of the deceased designated in a will or written instrument executed pursuant to Public
Health Ow section 4201.
-OR-
I � G I/We have Iw knowledge that the deceased executed a written instrument pursuant to Public Health law section 4201 or
will Containing directions for the i isp rdmion of his or her remains and )Continued neat page)
G ymssmaayrt..m/sal dceaoMa Pfsda
[am/We are the persoi having priority under Public Health Law section 4201 and have the right to authorize cremation
of the remains ofthe deceased. My/OurmWb IPW me deceaed is as filbws:
(InfraJrwn the let West
Number.�Deecri stion'. Uj v��
A lesson deagneled in wrong pursuant to Public Health taw section 4201 (3).
I. The surviving spouse;
. The surviving domestic partner
3. Any surviving child eighteen years of age or older;
4. A survivirrg parent:
5. A surviving sibling eighteen years of age or clams
8. A lawfully appointed guardian.
T. Any person(s)eighteen years of age or oltlerentitled to share in Me estate and who haters rimester in
relationship to the deceased:
8. A duly appointed fiduciary of the estate;
9. A does friend or relative who has executed a written sratemenl pursuant LO Public Heats Law§4201(]);
10. A chief fiscal officer M a county of a public administrator appo arm! pursuant M the Sumogatds Court
Procedure Aral;
10a.Any after person who is ailing on behalf of Me dereautl and win has execo ed a written apartment pursuant
to Public Hmlth Law§4201(7).
hi ALITHRFFn)Ihe/ulbevew)
J'Q 0— I/We hereby affirm that the eddy of the deceased tices not contain a beery, battery pack, power cells radioactive,
implant, or radioactive device and that any such materials were removed prior to the execution of Authorization Form.
Fallu rt t0 eemore IM1eu Nees PrIPr to aematlPn may mutt In Mrm to tM1e ereme[Pry end amramry personnel.
J_C (r IAYe hereby affirm that instructions have been given to pvm,wa..nm.m.rl [asslo Ralkrtv P141W starting the
removal of any Personal property or other thing of value which any pecan signing below or any family member of the deceased
wishes to preserve. (eemowrwn) Pine View Crematory s nth responsible for removal of Personal
items from the container or from the remains of the deceased. Personal items NN Isthe sentence or win the remalm will be
destroyed by the coverage, process and cannot retrieved allies Plma[mn.
Xa 0 — I/We tender authorize semnmzmel Pirre ykw crematory to connotes the remains of
the deceased.
FINAL DISPOSITON
The person authorized to receive the cremated tankers of Me deceeetl ham the ire ntai Is:
Name'. Baker Funeral Home personnel
Address: 11 Lasincylas Speed QueemouN New York 12804 Phone: (5181 TB1-0 3
The cremated remains of deceased will be disposed of as Mows
Retum to fanny M he handed
If Many reason Me person named above does not take possession of the cremated remains,
lnurewrnwnw Plne Uew CremeMrv
a authorized Lin give pmssesslm of Me remainsW
Wexxxv, el Ba4er Funeral Xome by delivery In person or by registered mail.
pcs1Mra so plAN G C,L0,1 e+e Lers
Y
(Ipj(jQl fire Jollowln9l
zs-C G IMIe understand Mal tithe remains are ne canned within 120 days of cremetmn,
rc..emyiwil PIMM Crommurf may disease oftbe remains in an inemwaMe manner,
such as by soldering.
fR TIONCONTAINERNRN
InlfblONEalldeJolbwirgl
An urn b the used as a container for Me cremated remains has been purchased!horn Baker
Funeral Home and is desrnbed as fdkrv5:
IM§ understand that if Me um is too smell b hod Me enfre cremated remains, an additional rigid mntamer may be used
for delivery.
OR
f4 G An um has red yet bem purchased_ INYe understand Met no um is purthasttl or oNelwise prwmed lowanm,
iwrel P"ne V CremaMry will place the cremated remains In a raid Wmpomry
container for Mile",
This Astronomer Form was provided by pwewamnrmmp fassia kaffertv#103W
was executed at uimmd Baker Funxal HOme
(rwwwmmeww) 11 Latavetle Street Oueanabury New Volk 12800 and is signed "a lunerm director
as winners to its evecudan.
IM4 have resonant a completed copy of this AUMonzadon Form
The perms (s) menfi(dbebw,Were the perssrn(s) in conbol ofdisposiliki who by signing Mis AUModzafion
Form, attest(s) to die accuracy and ccmpleminess of Me inlormetion confirmed in has AUMMzabon Form and
authm¢e(s) Me foregoing
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WITNESS:Caava RaRcvN
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