Venn, Eileen P Authorization for Cremation and Disposition
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MIS APlhor/zadoa For Min bit can~wMaipnedpriw W Sa0eway of remains tar erematlon.
Date: $124 ITC Number �b
Crematory Name: Pine View Cremadd
Address; Quaker Rued, Du ssommury, New VOM 128M Phone: 518)7454477
CREMATION IS AN IBBEVEIIBIBLE AND FINAL PROCEBB.
Cremation is carried out by placing the remains of the deceased and the container holding the remains into a
cremation chamberwhere they are subjected to intense heat andflame.The heat and name all mainstream and wmume
everytNry batept bane antl mi which are all tM1m will has left that cremator
Following cremation, the crematory will take reasonable eff any to remove an of the remains and abler material ham the
cremation chamber, but some minimal dust and residue will IIkeIV be Ieh 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 pulverized into small places and placed into a designated container or urn. Cmnrted
mains genealry are pmvermsd until no single lmgment is recompable as""[Issue.
OPENING OF CONTAINER
The crematory may only open the container holding the unrbonat ed human remains in limited circumstances, sum as to
confirm the identity of the deceased or to ensure that no material is enclosed which might Injure employees or damage
crematory prope". if human remains am delivered in a combiner whether is not sulMNe far cremation such asmoNal or
rental wskm,the nemMory will require fiat the remains he moved Into a suitable whaler beore it accepts the remains. The
opening of a container 0r 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 Department: )<.i it /1 t' Venn Marcel Statlm: _
Laval mnAadreea: 1110 Sot A hw k "Ll inntmode C4AnrF IF 44991
Place off Deans hirz✓fin Vk_ S} I` rk I FI 3yS�1
Sea OM OF oOR: 7�9911q r, DBteM Oeetk Rl �3�?0Z0 EstimatedWei9M: 1�
Description of w natirmntainer in which remains will be delivered:
Corrugated Cardboard Box with Piedmont Starmark Model#38808
PERSON IN CONTROL OF DISPOSITION
(Peraonjs) In wntwl of disposition, initial ONE of the following)
I ant We are the designated agent of the deceased moderated in a will or written instrument executed pursuant t0 Public
Health law sermon 42O1.
-OR-
AA* I/We have lw knowledge that the deceased executed a written instrument pursuant to Public Health Law section 4201 or
will containing dirm iOnsfor the disposition of his or her remains and (Continued next page)
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lam/we are the person(s) having priority under Public Health taw sectio 4201 and bass the righlto eushoriaecremaran
of the remains oft he deceased.lsii relationship to the duxsW h as follows:
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comber 3 cescrimi0n'. k dcl4tler
A person designated in warning Dursul one Heats Law seems 4201 (3):
2. Thrsurvivirgspouse',
L.The surviving domestic paMer,
3. Any surviving child eighteen years of age or older,
A A remaining parent;
5. A surviving fencing eighteen years of age or older,
S. A lawfully appointed guardians
]. Any persons) eighteen years of age or older endged to share in Me estate and who Ware dosest in
relationship to Me Medical
B. A duly appointedfiduciary oftheestata:
e. A dose Mend or relame 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 appareled pursuant to the Surrogate's Court
Procedure Aa;
10a. Any other perscn who is acting on behalf of Me deceased and who has executed a written statement pursuant
W Puck Health Lew§4201(7).
atdar A((THREEDf we Afford")
neap pale hereby affirm that the body of the deceased does not contain ahattery,battery pack power cell, radioactive
implant,or radvcccthe device and that any such materials were removed prior to the execution of this Authorization Form.
Failure to remove these Items prior to precision may rewit In harm W the aemamry and Cematary personnel.
/y A,,, I/Wehereby affirm that instructions have beengiventoac, me .rvj Gssb Ho%em Al41X regarding the
removal of any personal property or other thing of value which any person signing below or any family member 0 the deceased
wishes to preserve. Ive.ercnnemel Pine View Cremators s not responsible for removal of personal
items men the comamer or from the remains of the deceased Personal Items left In the container orwith the remains will be
destroyed by the amaton process cord cannot be retrieved aRx premamn.
P q.A I/We hereby authrrltt rmmaan ,o Pine View Crematory to aemao the remains of
the decreased.
FINhLDIsPosmON
The person auNonzed to receive the cremated remains of the deceased from the crematory is:
Name: Baker Funeral Home Permnnel
Address, 11 Latinette Strelit, Quiversburry New York 128M Phone: 518) 761-9303
The cremated because of Musical will thus,disposed of as follows
Realm to family to be decided
If for any reason Me person named above does not Mke possession of the cremated remains,
(anyway a Pine Vlew Crematory auMonzed W give possession of Me remains to
rywrviv,,, el Baker Funeral Mome by delivery In person or by registered mail.
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INVa unicameral Mat dMe remains are nevWmsd arNn 120 days of oemation,
losraxrrn.�xl P'neV Cremamry may disease of Me remains in an inebisvable manner,
such as by scattering.
CREMATION CONTAINERNRN
I nilb ONE of the fnlroW c)
An um to be used as a container fw the cremated remains has been purchased from Baker
Funeral Nome and is tlescdbed as follows:
INfe understand Mat if the urn is too small to hold Me share cremated remains, an additional rigid container may, Its,used
for delvery.
OR
—,V ¢An um has not yet been purchased lMmunderstand Mal R no um is Purchasetl or pMervnse provided lo.m.my
xm1 Pine View Crememry will place the cremated remains in a rga temporary
container for delivery.
This Authorization Farm was provided by P ussm,mmel fsss'a Rafler[v#1C100
was executed at ex,xa� l Baker Funeral Rome
Mnenmomewaw) 11 Lafavetle Streit. Qucensbury Nee Yark 1280C and is signed by Me funeral diracMr
as int ess m its execution.
IMN have received a completed coy of Mis Authonza0on Form.
The parents) abandoned below Word Me persen(a) in senor ofboathouse, who by signing We AUModzafmrr
Fonn, attests) to the accuracy and complalerress of Me (nkrmation contaitled M this Aullrortatbn Form and
authorizes) Ma foregw'np
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WITNESS: l(�•
Cassia RaffeM li4Ml 1
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Funeral Home Red. 0101130
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Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NV 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: _
— _hC$L' _. RETURN TIME-
DATE R TIME REMAINS ARRIVED AT CREMATORY: _ �d
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMqIry
G+� ��
NAME: _. _"..L•' ..a
-" _C48Ep __
TYPE Or CONTAINER _. Grilc.�.G,o�a�.__1s GwL- Sl..w N B
PLACE OF DEATH:
ESTIMATED WEIGHT OF REMAINS SCONTAINER__
PLACED IN HOLD:
PLACED IN REFRIGERATION; ___ -�
00.TF OF CREMATION-
TIME STARTE@ _—
TIME COMPLETED _ 2,
PLACED IN RETORT: —_ �:-[ n
. .-. ...___MOVED: . _ L _ftlr Z/iS
RETORT INWryICH REMAINS WERE CREMATED: _ _vz `I
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE A HOURS
FROM TIME OF ACCEPTED DELIVERY;
NOTE: HE CREMATION LOG SHALL BE RETAINED ;N THE PERMANENT FILE OF THE Caemn Or Rv