Hatfield, Tanya M. Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: _ � pft i
[I[lam _—'— _. RETURN TIME _
DATE IS TIME REMA
INS ARRIVED REMFTORT
DIRECT RE
NAME OF FUNERAL DIRECTOR OR REGRISTEREO RE
$'DENY DELIVERING REM AINS:
NAME JI� L '+ijJl
__ 9y f{
CgbE R _
TYPE OF CONTAINER: _
A-7 so
PLACE OF OEATN:
ESTIMATED WEIGHT OF REMAINS 8 CONTAINER _.
PLACED IN HOLD: -__-- --
__ _
PLACED IN REFRIGERATION:
DATE OF CREMATION: zI 70
TIME STARTED: J:O)Mn —TIME COMPLETED:
PLACED IN RETORT: S —_._p
RETORT p IN WHICH REMAINS WERE CREMATED:
DETAILED REASON FOR DELAY IF HEMP INS WERE CREMATED MORE THAN VE HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SHALL PE RErwpeo N THE nERMANENT FILE OF YET CREMATORY,
Fix m .,
Authorization for Cremation and Disposition „e, ma dra ,mer
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This Armhadzaemn Form must be eomplmad mds4nWpdwta MNi of cousins fpreswma .
Date: Sibiu Number Ilp
Crematory Name: Pine View Crignal
Atldro s: Quaker Road, Oueensbury. New Vork 10804 Phmle: 51R1745-a4]]
CREMATION IS AN IRREVERgmI£AND FINAL PROCESS.
Cremation is carried out by placing the remains of the deceased and the container holding the remains into a
cremation chamber wherethey are subjected to Intense matand name.The Ma add flame will Indigenous and wnwme
everyMiry except bane and metal,which are all Mat will M all after ce aaon.
Following cremation, the crematory will take reasonable efforts to remove an of the remains and other material from the
cremation chamber, but some minimal dust and residue will likelybe haft behind The c marory will separate incidental and
foreign material from the remains and the incidental and foreign material will be disposed of as repuired by law.The
cremated remains
will be mechanically pdverlred Into small pieces and placed into a designated container or urn. Crcmated
mains gererallyam pulvMred uniel w Nngle fragment A Federici AS skeletal NNue.
OPENING OF CONTAINER
The c matory may only open the container holding the uncremated human remains in limited clrcumRance , such as to
wnflrm the Identlry of the deceased or to ensure that net material is enclosed when might Injure employees or damage
crematory propeM. If human remains are dAAmdJ In a container which Is sent suitable for cr maflon such as a ceremoned w
mMalo ,the cmmmary will require Mal the rtm ns M mdvM into a sutable container belwe N a= N 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 DECEASED (�
Name Of Deceased fri M HAeld Mantel Status:"tni Voters 1
Last Known Addrece: 11 I (y�1 .. & S ATt4„�i 3 Mijr F� Al 4 12F2g
Place of DeaM: �yp 5 F II t1 'fL1� T' s`1I
Sex: DM OF aae: tt 'B1 I l'iI ISl2 oateof oeaM:��j EAimaledwagM: LMyC
Description of casket/container in which remains will be delivered:
Corrugated Cardiduldl Box with Plywood mark MoMll log
PERSON IN CONTROL OF DISPOSITION
fixerwn(s) in central of disposition, initial ONE of the following)
I all We are the designated agent of the decreased designated in a will or written Instrument executed purwant to Public
Health law When 4201.
-OR-
I/We have no knowledge that the deceased executed a written instrument pursuant to Public Health Law section 4201 or
Mill'oontaining directions for the disposition of his or her remains and(Commiled next page)
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l am/we arc the persom6l having priority under Public Health taw settion 4201 and have the right to authorise cremation
d me remains Pithe deceased. M fti relationship tothe deceased Is as follows:
Ameri�1th4se Jetbelpwl \
Numbm'?t? •'1 Description: OWna_ 'L 02( kra�
A person designated! in writing pursuant to Public Hus ltlt Law section 4201 (3),
h.The surviving domestic padner'
3. Any savmn eighteen years of age or older;
4. A surviving parent;
S. A eurvul sibling eighteen years of age or older;
6. A IawWltyapponstedguardian',
1. Any persu n(s) eighteen years of age or older entitled to share in Me estate and who iWare dosest in
relationship to the deceased',
B. Aduly appointed fiduciary of Me estate',
6. A close friend or relative who has executed a written statement pursuant W Public Health Law §4201(1):
10. A chief fiscal officer 0 a county or a public administrator appointed pursuant to Me Surrogate'a Court
Procedure Act;
10a.My other scratch who is acting on behalf of Me deceased and who has executed a smash statement pursuant
to Public Health Lew§4201(7).
dds)dnl♦LL THPEEofdefole inyf
y77v� I/We hereby affirm that the hotly of the deceased does not contain a battery, battery pack, power cell, radical
Implant, or redioactive devire and that any such materials were removetl prior tot he Wei Ion of this flumhorisMion form.
Fallureta removethese Items prlab memadon maymsuh In harmtotM cram moryand mematory personnel.
I/We hereby affirm that linstruct Ions have been oven to gww4eenw�w.el CassaaoHem Ml41W regarding the
remwal of any personal property or other thing of value which any person signing below or any family member ol the dereared
wishes to preserve, n..wnwww.l Pine View Cremctory is not responsible for removal of pelonal
items from the container or from the remains tcf the deceased. Permnat items left in Me container or with Me remains will be
destroyed by the Protection places and water be mounted afro chamber.
My.MqI/We hereby authirlum wmaymmel PI V C matory to owners the remains of
dmeased.
FINAL O SPOSmON
The person authorizetl M receive the cremated remains of the deceased from the crematory is:
Name. B P
Address, 11 L kwrafte,$=L Queembery liffig York 12804 Phone: (518)761d303
The cremated remains of deceased will be disp cared of as follows:
Newm 0 family to be,deddm
If for any reason Me mrson named above does not have possession 0the cremated remains,
saemercnnew.) P' atermi iced to give possession of Min remains to
rew.lmmenvmel Baker Fun ral Nom by delivery in person or by registered mail.
T Ha+Fall
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(ILyy the folmwmq)
I/We understand that if N remains are net me rem claimed within 120 days of cation,
Irml Pine View Crerrarory may dispose of the remains in an irremovable manner,
such as by scattering.
CREMATION CONTAINERNRN
riniriolowEojthefolbwinBl
_An om to be used as a containerforthe cremated remains has been purchased from Baker
Funeral Home and as described as follows
INR understood Net ff the um Is tap small fo hold the entire cremated remains, an a ldoonal Nat container mry be used
for delivery.
-OF-
MQP An urn has not yet best purchased. INJa understand Nat if no um is purchased or otherwise Provided A,,wwy
rowel Pine Yew CremaNry will place Ilse cremated remains in a NO h mporary
container for delivery.
This Authorization Form was provided by µnendmw wmrl CAia Reffe
was executed at µw.orrowewmN Baker wneral lfom
rmm.+nwa.wswp 11 New and is signed by the funeral director
as witness N its execution.
INIe have received a completed copy of this Authorization Form.
The persons) idenh(e[I Mow ottera the parsons) in comml ofdisposilron, who by tagning this Authorization
Form, aftest(sl to the accuracy and completeness of Me automation canommol in this Authorization Form amid
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WITNESS:
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