Starks, Raymond Floyd Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (SIB) 745-4476
FUNERAL HOME: __ _AI,pAFN
—_-_—..__,__ ,__,_- RETURN TIME:
DATE BTIME REMAINS ARRIVED AT CREMATORY; alb ix tvfh
NAME OF FUNERAL DIRECTOR OR RREGRIS�TCRTIE'O�RESIDENT DELIVERING REMAINS:
NAME: _.__._. .1'lE1� _„.--'J9Q W _ _SP ___CASE IT _
TYPE OF CONTAINER: _N' -- �4
PLACE OF DEATH: -______�ly.._ j - �•W Y ' T•
ESTIMATED WEIGHT OF REMAINS 8 CONTAINER_____
PLACED IN NOLO: '( (a
PLACEDIN REFRIGERATION: __
OpTE OF CREMATION; _
TIME STARTED: _- )_00fm _T AE COMPLETED:
PLACED IN RETORT: I1E6Q /_{D
RETORT # IN WHICH REMAINS WERE CREMATED:
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SHALL BE RETAIN" IN THE PERMANENT PRE OF THE CREMATORY.
Authorization for Cremation and Disposition ""u 01If li"a n
Ore Commrm PWa, 98 WmalnaWO Avenue
AI 31
518)i aaxxe
w,...Imitate.nr ve
Th/a Audmdzatlon Form must be eomplebd and signed ptlor b MNl of remains for crosdcn.
Date: OWM020 Number
Crematory Name: Phre View Crematorium /
Address'. Quakel Road n eeneM .v NY 121304 Phone: l4}5
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation is carried out by placing the remains of the recovered and the container holding the remains into a
cremation chamber where they are subjected to intense heat and flame. The heat and flame will Incinerate and
consume everything except bone and matal, which are all that will be left after cremation.
Following cremation, the crematory will take reasonable efforts to remove all of the remains and other material from
the cremation 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 cremated remains will be mechanically pulverized into small pieces and placed into a
designated container or urn, Counsel remains generally are pulverized 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 limited circumstances, such
as to confirm the identity of the deceased orto 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 cremagon
such as a ceremonial or rental casket, the crematory will require that the remains he moved into a suitable
container before R 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 dignity and respect.
IDENTIFICATION OF DECEASED
Name of Deceased. _R_ ymond Floyd Starks Mantal Status: Widowed
Last Known Address 36 ]On Ave, Hudson Falls New York 12839
Place of Death: GI Falls Hears) GI s Falls New York 12801
SaxeM F Age: 85 DOB: 03/1N1935 Date of Death: 08117/2020 Estimated Weyht:- 7bS�6,{
Description of ceskeVcontainer in which remains will he delivered. Matthews Cremation Cese
Cardboard toplplywo0d bottom
PERSON IN CONTROL OF DISPOSITION
(Farsonte) in counter ofenewhon. BONE Of the 1000w1ng)
I am/We are the designated agent of the deceased designated in a will or will instrument executed
pursuant to Public Health Law section 4201.
s RENV Aff have no knowledge that the deceased executed a written in ummmnt pursuant to Public Health Law
201 or a will containing directions for the disposition of his or her remains and rc inked nextpage)
Raymond Floyd Stales
DOG laun.a(Res. 01110) NimemCYweeeO Ihp+ as
I any we are the personas) having priority under Public Health Law section 4201 and have the right to authortre
cremation of the remains of the deceasetl. fill lour relationship W the deceased Is as follows:
flash from the tut below)
Number 3 Description' son
1. A person designated in writing pursuant to Pull Health Law section 4201(3):
2. The surviving spouse;
2a. The surviving domestic partner',
3. Any surviving child eighteen years of age or older',
4. A surviving parent,
S. A surviving sibling eighteen yearn of age or older;
8. A lawfully appointed guaNian;
y. Any person(s) eighteen years of age or older entitled to share in the estate and who is/are closest in
relationship to the deceased;
8. A duly appointed fiduciary of the estate;
8. A close Mend or relative who has executed a written statement pursuant to Public Health Law §4201(]);
10. A chief fiscal officer of a county or a public administrator appointed pursuant to the Surrogate Court
Procedure Ad;
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(2)
(Inl_el ALL 1HftEE of the following)
IMil hereby affirm that the body of the deceased does not contain a battery, battery pack power cell,
tl oa ive implant, or radioactive device and that any such materials were removed prior to the execution of this
Authorization Form. Failure to remove these items prior to orientation may result In harm to Me crematory and
crematory personnel.
Me hereby affirm that instructions have been given to (Iumnl4iecMn,mq Cassandre S. Maille
regard) g 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 Pine View Crematorium anor
responsible for removal of personal items from the eontainer or from the remains of the deceased. Personal Items
Ii in the container or with the remains will be destroyed by the emanation process and cannot be retrieved
Zcro matlon.
Initial hereby authorize lmmmm,,�re) Pine View Crematonum to diameterthe
erns of the deceased.
FINAL DISPOSITION
The person unhorsed to receive the cremated remains of the deceasetl from the crematory w:
Name: Carleton Funeral Home Inc.
Address. 68 Main Street, Hudson Fella W 12839 Phone: 518-7494113
The cremated remains of deceasetl will be disposed d ea follows:
bwA I �+ AACS( \ l Pma'�f/{/
If for any mason the person named above does not take pos sion of the cremated remains.
tmm,myn.m i Pine View Crematory is Whorl to give possession of the remains to
(rvunmrwmi Carleton Funeral Home, Inc. by delivery in Person or by registered mail.
12aymi Floyd Studies
Dos-181 ma, mo01 wm,aw a, xy12d3
flnaial me following)
IAVe understand that 8 the remains are not claimed within 120 days of cremation,
I eel Pine View Crematorium may dispose of the remains in an Irretrievable manner,
such as by scattering.
CREMATION CONTAINERIIIRN
(Initial ONE of the hollowing)
An urn to be used as a container for the cremated remains has been purchased from
Carleton Funeral Home, Inc.. and is deaaibad as follows:
[Me understand that if the urn is too small to hold the ern ire cremated remains, an additional rigid container may be
used for delivery.
An um has not yet been purchased. Wde understand that if no urn is purchased or othermse provided
I mxay . ) Pine View Crematorium will place the cremated remains in a rigid temporary
container for delivery.
The Authorization Form was provided by ywnmw vnima) Cassandra S. Maille
was executed at rnmamlhom.,mms) Carleton Funeral Home, Inc.
AwmII h m adema 68 Main Street, Hudson Falls, NY 12839 and is signed by the funeral director
as witness to its execution.
IANe have received a completed copy of this Authorization Form.
The perennial identified below islare the person(s) in control of disposition, who by signing this
Authorization Form, thwart m Me accuracy and completeness of the Information contained in this
Authorization Form and authodze(a) the foregoing.
SignGetl tM1ia �./18 Itlay of An ust 20
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Address
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Address
WITNESS: /7
Cassandra S. M®Ile �n�f/
wyry atia.Yp TyIMq Win9e Nmm Fumnleincbr5gnelun
14257
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Raymond Floyd Stacks
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