O'Leary,John J. Jr. Fine View Cemetery & Crematorium
quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745.4476
FUNERALHOME: __ q{L..
- —"'-- .rMea --- ___ RETURN TIME: p�p�__... _. ..___LL±LL_—.
DATE 8 TIME REMAINS ARRIVED AT CREMATORY:
Jn_6q(7 NAME OF FUNERAL DIRECTOR OR REGgISTERED ---
RESIDENT DELIVERING REMAINS-
NAME: IT
"se
TYPE OF CONTAINER: —_ _ * __PrA�CY
°ueE of DegrM.
ESTIMATED WEIGHT OF REMAINS 8 CONTAINER. ,,II
PLACED IN NOLO:
PLACEO IN REFRIGERATION: ____
DATE OF CREMATION:
TIMF STARTED: _ _[O_J�?I_.._nmE COMPLETED: 11_n�M
PLACED IN RETORT. --_@:YEAT� ._.__ _MOVED: _ JD +AT'1 /LI(f�l.�
RETORT HIN WHICH REMAINS WERE CREMATED: _ -- _ --,+��-� -lmI "
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MOETHA 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE. THE CREMATION LOG SHALL Of RE gwEO IN THE PERMANENT FILE OF THE tREMATORv.
ass onani
'Authorization for Cremation and Disposition uhman
on,[lima is a, onpw"i
ells ei.n>eve
This AU udzadon Form must be mmplN and signed prior to delivery of remains for Cremation.
Date: 1131 za Nudoer 117
Crematory Name: P'ne Yew ommatm
Address: Quaker Road, Quaenabury. Have York 12904 Phone: 5181745-4hI77
CREMATION IS AN IRREVERSIBLE AND FINRL PROCESS.
Cremation Is carried out bV alarm t the remains of the deceased and the container holding the remains into a
cremation chamber where theyare subjected to intense regionalflame.The Mat also Name will Indo e cons tame
and conme
e verything except bane and megdsyShkM1 are all that will be left after cremation.
Following cremetion, the crematory will take reasonable eff ones to remove a n of the re mains and urn er material from the
ore mation chabar, but same minimal dust and residue wl11likely be left behind.The crematory All separate Inadental and
fore m
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 her small ounces and placed into a designated Wntalner or um.Cfematad
remains generally are WNM[etl umll no tilde frig Bre la Assaideal Doug.
OPENING OF CONTAINER
The crematory may only open the container holding the on cremated human remains In limited circumstances, such as to
confirm the Ideal of the deceased or to ensure that no material is enclosed which might Injure employees or damage
crematory property. If human remain am hllened In a container which Is not uitable for cre"im such As a orremmlal or
rental caskeq them esMOry will require thatthe remain be cowed Into a suitable container Eefors It accepts the remalm.TM1e
opening of container n or the transfer or removal of remains will be conducted before a witness and will be done In powers,
with dignity and respect.
IDENTIFICATION OF DECEASED 1
Name of Deceased. V'ifl fq 1 O'/ ann� �/- MerXel Statue:. !Wr n.rl
Last Known Address: 'Ru I pu ronpa s NU 12801
Place of Deelh: Rti
Sex: KM OF Age, 5S DORI 8J5119L6p of Death'. q 1 2= Eatimata igM: 185
Description of crsket/coldalner in which remains will be delivered:
Corrugated Candegard Box with Plywood Starmark Metl 880g
PERSON IN CONTROL OF DISPOSITION
presonlsj in central 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 Law union 4201.
-OR-
OVI-I/We have no knowledge that the deceased executed a written Instrument pursuant to Public Health Law section 4201 or
will containing teachers for the disposition of his or her remains and (Continued next Page)
6 P
om.Lwr lee, Whe aeneefamnaa L *°I'
I ant we are the cerson(e) having priority under Public Health Law seRmn 42a1 and have the right to authorize cremation
of the remains of the deceased My/Our relationship to the deceased Is asbllover
newit)mm/merlin below
Number "S Descriptor:
A person deagnated in venting pursuant to Public Health Law section 4201 (3),
2. Thesurvivingspouse;
2a. The surviving domestic banner
3. Any surviving child eighteen years of age or older
4. A surviving parent;
A surviving sibling eighteen years of age or older
G A lawfully appointed guard aol
T. Any parsons) eighteen years of age or older eni to share in the estate and who israre closest in
relationship to the deceased'.
S. A duly appointed fiduciary of Me estate;
9. A close Mend or relative who has enectted a whiten satement pursuant to Public Health Law §42(1
10. A chief fiscal officer of a county or a ought administrator appointed pursuant to the Surrogate's Court
Procedure Act
100.Any other person who is acting on behalf of to deceased and who has executed a women statement pursuant
W Public Health Lax§4201(7).
onea lgLL rMFFEaj rhe)olaw y)
��"�A I/We hereby affirm that the body,of the deceased does not contain a battery, battery Pack, power cell, radioactive
1(ITplant,o red load me device and that any such materials were renewed prior to the execration ofthis Authorization Form.
Failure to remove new Items prior 10 crematlm may news in rams w the cremamry and crematory personal.
�p"vI/We hereby affirm that Instructions have been given to 0.,< w.ror. i H Mlslao regarding the
vd hw of any personal property or other thing of value which any person signing below or any family member of the deceased
wishes to massive. Fine view Ijuarrecomi nor responsible for removal of personal
items from the container or from the remains of the deceased. Porsoal Items left In the wntalner or with the resume sell be
destroyed by the comatose oc ess and cannot be removed after cremation.
ry„1n I/We hereby awhorize liv,mv cremate Me remi of
"tNld V setl.
FINAL DISPOSITION
The parson armanzed W receive the Cremated remains W the tie wasa] from the crematory is
Name: H
Address: 11 1 shavens fiffeet Quarainstary IN w Yet Phan. 1510 T814303
The cremated remains of tleceasetl will be disposed Of es IOIIoxs:
Realm to hmily ro be degtletl
If far any reason the Person named above tices not bake possession Of the cram remains.
ho maal,.mwl is amboraed to give possession NMe remains to
lrynnm nmm minx Bkp IN by delivery in Person or by registered mail.
T D Lean
ooszma„Iw.mom w^�^,
Irnirbl Mejolbwlnq)
�o}�IA1 looks understand Mat if the remains are notdreimed At in 120 days of cremation,
orwri ui Rne ViewCremati Trey dispose of Me remains in an unscramble manner,
such as by scathing.
CREMATION CONTAINEFiURN
Inirer ONE of tMhllowing)
An um to be used as a wMamerfor the cremated remains has been purchased from Baker
Funeral Home and is described as fallows:
IIWe understand Met ifthe um is We small W hold the snare centered remains, an additional rigid container may be used
for delivery.
OORI.
2kd An urn has not yet been purchased IM'e understand that Of no urn as purchased or otherwise provided rwmum
cowl Pine Yew Crematory will place the cremated remains in a ngid temporery
corHainer for delivery.
This Authoriaatbn Term was provided by µnenimmwmmml Oci RateiW
was executed at yv,,vv =morel Baker funeral Home
MnwwnmaeUYe¢l B O b aM is signed by Me Mreal director
as Access W its execution
mom have received a completed copy of this Authorrzation Form.
The perean(s)identifed below Wars the person(sJ in condor of del sir n, extra by signing Mis Attenuation
Form, i ffeat(s) to the accuracy and completeness of Me lnformadon contarel in Mrs Armorial Form and
elemental the(oreiromi
Slimed this 3 dry of 30 20
,ro,aeh
Ads" u7U Q� t��� r y
.exr ermer Swears,,
WI aTNESS:
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Funeral Home Bea W1130
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