Lemery, Steven Edward Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: gdl _ -.
____._ RETURN TIME n
DATE 8 TIME REMAINS ARRIVED AT CREMATORY: p
NAME OF FUNERAL DIRECTOR OR REGRISTERED AES��_ (Y/S- ZO T)
yy� DELIVERING REMAINS:
NAME:
�_CASF p _
TVpI OF CONTAINS//R:11 -�' gkf�n
PLACE OF DEATH: .t2K�✓�._ 5 E� b,
'1�5 -/Cb - /fs
ESTIMATED WEIGHT OF REMAINS & CONTAINER_ IUD l
PLACED IN HOLD: �J PLgCE0 IN REFRIGERATION:
DATE OF CREMATION: Q-Es Zo ---
TIME STARTED; _TIME COMPLETED-
PLACED IN RETORT: y
-__MOVED;
RETORT
RETORT A IN WHICH REMAINS WERE CREMATED: PPS``
H1 9>-�k a
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 00 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CaemgnOx lop SMALL 6[ aErgixFo IN THE reamFxexi HLE OF THE cgemwmay.
Authorization for Cremation and Disposition "Ya pa orc'mettre
One comri maxa, as WaaMnglon Pvei
story NY 12231
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doe
MIS Aut dzadon Fonts must be completed and signed polar m dWNary of remains for cn 000n.
Date: 8/14R020 Number'. V4!
Crematory Name: Pine View Crematorium M
Address. Quaker Road Quernsbu NY 12804 Phonerjrj7��f-V / /
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation is carried out by plating the remains of the depressed and the container holding the remains into a
cremation chamber where they are subjectetl to intense heal and flame. The Neat and flame will Incinerate and
consume everything except bone and metal, which are all that will be left after cremation,
Fallowing emission, the crematory will take reasonable efforts to remove all of the remains and other materiel from
the cremation chamber but some minimal dust and residue will likely be left behind The crematory will separate
incidental and foreign materiel from the remains and the incidental and foreign material will be disposed of as
required by law. The aemated remains will be mechanically pulverised into small pieces and placed into a
designated container or urn', Cremated remains generally are pantomimed until no single fragment is
recognizable as skeletal tissue.
OPENING OF CONTAINER.
The crematory may only open the container holding the un-cremated human remains in limhad clmumstanoes, 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 normal casket, Me crematory will require Mat the remains be moved Into a soluble
container before it accepts the 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 dignify and respect.
IDENTIFICATION OF DECEASED
Name of Deceased. Steven Edward Lemery Mantal SUNS: Never Married
Last Known Atldress: 17 Granview Dr. Granville New York 12832
Place of Death: Glens Falls Hospital Glens Falls New York 12801
Sex MO F Age: 63 DOB: 61 Date of Death: 08/I l/2020 Estimated Weight: lO
Description d caskedwnuiner in which remains will be delivered: Matthews Casket Co. Crertlation Case
Plywood bottom/carboard top
PERSON IN CONTROL OF DISPOSITION
(Person(s) in pontml Ofduldead al, loss ONE of'he foNowing)
I am/We are the designated agent of the deceased designated in a will or written instrument execmed
pursuant to Public Health Law secion 4201.
-OR-
Ai I/We have no knowledge that the deceased executed a random instrument pursuant to Public Health Law
section 42D1 or a all containing dlrCLdOns far the disposition of his Or her remains and (CMSnCadnewpage)
Steven Edward Lemery
oOS1ee&H saw 01110) Wme Nofwv! Pavel of
!!off Me twaw;npl
42011 Unte understand that d the remains are notf�ft claimed within 120 Says of cremation,
Such asby s Pine View Crematorium may Dispose of Me remain; in an irretrievable manner,
&Hall a8 by BCBIIBIInQ.
CNENATON CONTAINEFAIRRIN
(;alibi ONE oftne follomlrlpl
An urn to be used ea a container for Me cremated remains has been purchased from
Carleton Funeral Home Inc., and is described as follows:
used understand rdelivery
IM1at gthe um Is too small to hoW the entire Cremated remains, an additional rigid container may be
used for delivery.
-OR,-. G
_r.�,An um has not yet been purchasetl. We understand that Nino urn is purchased or otherwise orovid ad
tmmemynemml Pine View Crematorium will place the cremated remains in a rigitl temporary
container for delivery.
The Authorization Form was provided by (,„u„ra 'Iry new
was executed at ry,,,mrerxwre,,ar') Canards S Maille
nunem mm'e emnsn 68 Main Saes[ Hudson Fells NY1283g Funeml Home Inc.
as witness to its execution eM is ;igned by " f ffe ral director
(We have received a completed copy of this Authorization Form.
The Person(s) identified below ishere the person(s) In control of disposition, who by signing this
Authorization Form, attests) to the accuracy and completeness "a Information contained In this
Authorization Form(and auth irizita) the foregoing.
signed rob Y{ day of gosf zo zo .
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WITNESS: �/,•�� �
Cassavdre�S Maille x-O!L+tM0.(A ��
n„nwNo,,. rm.ewm„r.efm,s o�reuisM+ean
W t5l
a.a;.eaaar N.Nwe!
oosneas.0 rear. ornel Steven FAwerd I.=
N"Ma DaMi Vpe3p8
I ant we are me person(s) having priority under Public Health Law Motion 4201 and have the right to authorize
aamationoftlwremamsofthedereased. Myl0ur relationship to the deceaaed,ls as follows:
fln rent hom MB list below)
Number. 6 Description: guardian
1. A person designated in writing Pursuant to Public Health Law section 4201(3);
2. The surviving spouse:
28, 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 entitled to share in the estate and who islare closest in
relationship to the deceased,
S. A duly appointed fiduciary of the estate:
9. A close friend or relative who has executed a written statement pursuant to Public Health Law §4211
10. A chief fiscal officer of a County or a public administrator appointed pursuant to the Surrogate's Court
Procedure Act
10a. Any other person who is acting on behalf of the deceased and who has executed a written statement
Pursuant to Public Health Law §4201(7)
firs@el ALL THREE of the following)
4�k, i 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 ware removed prior to the execub'on of this
Authomuntion Form. Failure to remove these Items prior to cremation may result In harm to the crematory and
crematory personnel.
16L, We hereby affirm that instructions have been given to ryu...re aisewwnel Cassandra S. Maine
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. rm,� nail 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 reVleved
after cremation.
Mars hereby authorize io rr,w 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 in:
Name: Carleton Funeral Home, Inc
Address: 68 Main Street, Hudson Fails NY 12839 Phone: 518-74942A3
The cremated remains of deceased will be disposed of as follows:
Buried in Union Cemetery Fort Edward, NY
If for any reason the person named above does not take possession of the cremated remains,
rwmermw�o Pine View Crematory is authorized to give possession of the remains to
lwre.+mwnnem l Carleton Funeral Home, Inc, by delivery in Person or by registered mail.
Steven Edward Lemery
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