Goodsell, Donald Lee Pine V'RSV Cemetery g Crematorium
Quaker Road
Queensbury, NY 12504
(51a) 745-44777 or (510) 745-4476
FUNERAL HOME: . . _. ne 'a_V __ ..Fdl.
OR
---_._.. RETUgN TIMF: _
04TE & TIME REMAINS ARRIVED AT CREMATORY:
NAME OF FUNERAL DIRECTOR OR gEG �V'�REMAINS:
RISTER[O RESIDENT DELIVERING REMAINS:
NAME
_, cAbEM1
TYpEOF CONTgINFR: ] 1 Joel "—'
PLACE OF DEATH
ft€ems �Fro�-_ _v_u Iwy
ESTIMATED WEIGHT OF REMAINS S CONTAINER I O
PLACED IN HOLD:
M ap
PLACED 1N REFRIGERATION;
DATE OF CREMATION,
PLACED IN RED: ,_ Vf•y:(_ T:ME COMPLETeO _ 8��1n
PLACED IN RETORT _ Q.r�
RETORT P IN WHICH REMAINS WERE CREMATED:
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED —��
FROM TIME OF ACCEPTED DELIVERY: MORE THAN 40 HOURS
NOTE THEtReMATION LOG
Authorization for Cremation and Disposition "YONNGio ofCa'mmn
Om Lommeem Plaza,%W0011 olAwnue
Albany NY 12231
15101174E326
This AU ozl7a0on Form must be COIWGWWdsfgndpd"W delivery of remains for cremeeon.
Data; i/Stu Number 10O(
Crematory Name: PI Y C
AShiresa Quaker Rl Do-, sbury, New York 12800 Phone S19174S441fl7
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Chinaman is tarred out by placing me remains of the deceased and Me container holding the remains into a
cremation chamberwherethey aresubjectedto Intense heatand flame.The heat and flame will Incinerate and
consume everything except bone and need,which are all that will be left after cremation.
Following cremarl the crematory will take reasonable efforts to remove an of the remains and Other material ham
the mentation 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 crushed! remains will be mechanically pulverized into small pieces and placed into a
designated container or an Cremated remains generally are puh erized until no single fragment b recognizable
as skslehl the ue.
OPENING OF CONTAINER
The crematory may only open the container holding the un-cremated human remains in limited circumstances, such
as to confirm the identify 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 far cremaflon
such as a ceremonial or rental casket,the crematory will require that Me remains M am" into a suttabta
container More it accepts the remain. The opening of a container or the transfer or removal of remains will be
conducted before a witness and will be done in privai wish dignity and respect.
IDENTIFICATION OF DECEASED Gel
Name of Deceased LlvlaJli f�L l9CLY�SPX1 Metital Status: Lyack Xj
Last Known Address: �G J Ivrej� Wa�!iaurrri �� \aSDy
Place of Death: JO1 ( -Y5 QJPQ+1`aIIS.CT�1h), la-8oq
Sax. OM DF Age: SS DOB: 0-1/o{ ISI Date of Death- /O72O'p0 Estimated Weight 1401�h
Dentes-mon of ceskWcontainx in which remains will be delivered:
Corrugated Box- Plywood
PERSON IN CONTROL OF DISPOSITION
(Peraon(s)in copper ofdsposrtian, initial ONEorthe blowing)
enter We are the designated agent of the deceased designated! in a will or wWan instrument executed
pursuant to Public Health Law Section 4201.
-OR-
( I,. Nine have no knowledge that the deceased executed a written instrument pursuant to Public Health Law
section 4201 or a will containing directions for the disposition Of his or her remain``s and (1C1on6nued paMFey)
� ee J
coda lguy. IVI lj Nanuaoemwf I'pafaa
I amp we are the Senn )having priony under Public HeelM Law section 4201 and have Me rot to Subdues
cremation of the remains of Me Oeceaeed. all relationship to the deceased N as fellows:
(Inmd fiwn rat Ilst belowl
Number i—Oescrlp0on: (i(1 \C,FNPY
A person designated in venting pvmuant M Public Heath Law section 4201 (3);
2. The surviving spouse;
�2a.The survivingee domestic plu r;
shy. \ny surviving child eighteen years of age or older,
4. A surviving parent:
S. A surviving sibling eighteen years of age or older',
6. A lawfully appointed guardian',
T. Any person(s) eighteen years of age or older entitled M share in Me estate ano who ishare closest in
relationship to Me deceased)
S.A duly appointed fidudary of Me estate;
9.A close friend or relative who has executed a written statement pursuant M Public HBBIth Lew§4201(7):
10. A chief fiscal officer of a county or a public administrator appointed pursuant to the Surrogates Court
Procedure Act;
10a. Any other person who is acting on behalf of Me deceased and who has executed a whiten apartment
pursuant to Pudic HeaIM Law§4201(7).
add l{/1 LL THREE of the I Ski
CL(\ INVe hereby Sharon that the body of the de smsed does not contain a battery, ba0ery pack, power cell,
mdioac0ve implant, or retlioecfive device and Mat any such matenals were removed poor to the executlon of this
Authorpi Forth. Failure W remove Mate Bema prior to transition may result in harm to the crematory and
cnmi personnel.
K 7
U( INfa hereby persffirm onal
rty orother have been given to any person signing
57rowo HFYP2 regarding
the a sed wof any personal property ryn") thing of value which any person signing below or any family member of Me
deceaeetl wioM1 removal
preserve. ry aemry s from
P'M V'ew O re off
is not
theresponsiblecontainer
for removal of personal items from a by M et or from Me remains of the tlecee rist ParaoMl rmeet
inteleft in
the wntalner or with the remaiM w11160 deNroye0 by Me cremation probers;and as east be rNriwetl alter crematbn.
Ca Me hereby authorize ww ww•.mtl P' V' C b cremate the
rams of Me deceased.
FINAL OISPOSRION
The person au0mdzed M receive the cremated remains of the deceaeetl from;Me crematory is:
Name'. Baker F
Address'. 11 Larravehe Street Queeni New York 1213(st Phone: (518) 7618 03
The cremated remains of deceased will be disposed of as follows:
tt for any reason Me person named above dices not take possesson of the cremated remains,
(w,wivrpi P'ne View Cremebry Is auMomand to give possession of the remains
lrw..'w mra hems, B ice F H e by delivery in person or by registeretl had
tl D� Gi
p06i(a...etna) , aL%e..a Frea 2 w,
❑p@I91 Me btlpwingf
Q�T_Wge understand Mat d Me remains are not claimed within 120 days of cremation,
tc.,,ww .l Pine View Crematory may dispose of the remains in an irretrievable manner,
su0h as by suffering.
CREMATION COMAINERAIRN
rfnRiel ONE of the folKKtinld
An um to be used as a container for Me cremated remains has been pumased from
Maynard O. Baker Funeral Home and is described as follows:
We understand Mat ofMe um is too small to hold Me wrtlra communist! remains, an additional rigid container may be used
for delivery.
-OR-
An urn has not yet been purchased. [We understand Mat if no um is purchased or otherwise provided
lov„xav�.,,,q Pre View Crematory will place Me cremated remains in a rigid temporary
container for delivery.
This Authorization Fun sure provided by ttimaaredd,,.m l .STAR/C RAKr e djn 5
Was executed of lrvmealvmmm�) Baker Funera Home
*Wvrrvm pmvl 11 Lafavetle Street Oueensbury New York 12804 antl is solved! by Me funeral director
as Witness to its execution.
INVe have received a compleletl copy of this AUMONation Form.
The penanrs) Identified below islans the "man(*) In control of disposflon, who by signing thus Authorization
Fortin, adestrsi M the accuracy and competencies of the information contained in this Authorization Form and
authorlu(s) the foregoing.
Signed Mie Any of 20_
(Nr6f�ipl\ ��9
r�I cwhe �� rfne C�c1�� rCort NV QB31
Tro.ed,nux.urvw�. am.w.
Amw
rrrmsr�„mu Name sa"w"R
Adww
WITNESS:
S\e C v.1��eI LY11
surcN ouenwry[e]o'enwxc+w
Funeral Hone Reg. 0101130
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