Morrow, Alfred Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745.4476
FUNERAL HOME: ___
—'-onvw, RETURN TIME
GATE 8 TIME REMAINS ARRIVED AT CREMATORY:
NAME OF FUNERAL DIRECTOR OR REGRI$TERED RESIDENT DELIVERING REMAINS:
flow
NAME. kfK%P
TYPE OF CONTAINERLL(Arr 0 C>f1
PLACE OF DEATH: .__II _S,r .� �st- Slvti H�k Unit
__--------_,--
ESTIMgTEO WEIGHT OF REMAINS 8 CONTAINER__ ___-
yI1 E.
PLACED IN HOLD: —
PLACED IN REFRIGERATION:DpTE OF CREMATIONTIME STARTED:
: '-
b
—_TIME COMPLETED: 1
PLACED IN R HICH -]:+rWN _MOVED: ,__ _ --q
W
RETORT p IN WHICH REMAINS WERE CREMATED: 'J-•'-y-11• I '+„
—.-_ .
DETAILED SEASON FOR IF REMAINS WERE CREMATED Arm_-oval-_
MORE THAN V6 HOURS
FROM TIME OF ACCEPTED
DELI DELIVERY:
NOTE: THE CREMATION LOG SNAIL HE RETAINED :N THE PERMANENT SLED THE HE CREMAi
Authorization for Cremation and Disposition "°)1w(1�mfflu rs
ovecomm. O,w aewelhigmAmi
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TNfs AUMork n PomlmuM be compleNdaMMgrredpdor 0 dMnery of remains yor cremation.
Date. 2) /74 m Number IQ
Crematory Name. Pine V' Crematory
Address: Quaker Road Oueensbury. New Vork 12804 Phone: (518)75 TT
CRENIATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation is carried out by placing the remains of the deceased and Me container holding Me remains Into a
cremation chamber where they are subjected d Intense heat and flame.The heat and game will Inclrrerata and
consume everything except bone and metal, which are all that will bo leg attar cremation.
Following cremation, the crematory will take reasonable efforts to remove an of the remains and other material from
Me cremation chamber, but some minimM dust and residue will likely be left behind. The crematory will separate
inaden al and foreign material from the remains and Me mc'Idental and foreign material wtll be disposed of as
required by law. The cremated remains will be mechanically pulvenzed Into small pieces and placed Into a
designated container or urn. Comment remains generally are pulverized until no single fragment is recognizable
as skeletal tMsue.
OPENING OF CONTAINER
The crematory may only open the container holding Me un-cremated human remains in limited circumstances, such
as to confirm the lderNhy of Me con ea red or to ensure that no material is encloses which might injure employees or
damage crematory property. If human remains are delnefed In a container which is not suitable for cremation
such as a ceremonial or metal casket,Use crematory will require Mel the remains be moved into a suitable
container Were N accepts the remains. The opening of a container or the transfer or removal of remains will be
conducted before a wftness and will be done in privary, with dignity and respect.
IDENTIFICATION OF DECEASED
Name of Deceased. Alt-Yc(T MAorrcii) .. II� 1M1irgbastra w idow
Laid Known Addrreeas�: I Stwe Pine Ikyi tL Q�.f(CRCbIAA l�
Pram of Death. Yl(. nt: 7
sex: N(M of Age: oa -I-Dataof Death: 7p agmered weight:-✓L(Y�
Description of makelcontaimr in when remains will to,delivered:
Correlated Cardboard Box w1M Plywood Stermerk Model a MN
PERSON IN CONTROL OF DISPOSITION
(Pefson(s) in control of depositor, ini ONE M the following)
ant Vile are the doing noted agent of the disposed designated in a will or written instrument executed
pure ant to Public Heabh Law section 4201.
-OR
.AAr-..,,11
1•� _ Also have no knowledge that the Deceased executed a written instrument pursuant to Public Heats law
section 4201 ore will containing directions for Me disposition Of his or her remains
and (Conanaadnwzwwl
pos-Ieeau law. Iv11) mm. ao....Ae� use,
I aMwe ere Me oereon(s) having priority under Public Health Law section 4201 and have the right to authorize
cremation of Me remains of the deceased. Myli relatlonshlp to the deceased is as follows:
(Insert from line list denow)
Number: '6 Descmation:
A person designated in writing pureuant Pul Headh Law section 4201 (3);
2 The surviving spouse;
ga. The sublmig normal paMer.
�w Any survival ci eighteen years of age or Older.
4. A surviving parent,
9. A surviving sibling signal years of age or older;
8. A lawfully appointed Merchant,
t. Any demon(s) signal years of age or older entitled to share in the annual and who ishim closest in
relationship M Me deceased;
S.A duty appointed fiduciary of Me estate;
9.A close friend or relanve who has executed a wnmen entertainment pursuant to Public Hexllb Law§4201 p):
10. A chief fiscal officer of a county or a Public administrator appointed pursuant to Me Sunogate'e Court
Procedure Act;
Iii Any other person who is acting on behalf of Me deceased and who has executed a written statement
purspent to Public HeaIM Law§42O1
laigai 1LL THREE of has MMnng)
mm IANe hereby affirm thnt the body of the deceased does not contain a battery, battery pi power cell,
mtlioactive implant, or radioactive device and Mat any such materials were removed pdm to Me execution of the
Authorization Foml. Failure M remove Masse dams prier to model may mi in ham to Me crematory and
crematory personnel.
1„IA1 ut It hereby aMnn Mel instructions have been given to lwreiw w.,. ) SI fytol8g regarding
Me removal of any personal property or other thing of value which any person signing below or any family member of the
tleceased wisM1es td preserve. t .ar^"*el Pine View Crematory is not responsible for
removal of personal items from the container or from Me remains of the deceased. Personal Hama bh In Me container or
win NM^e remains will he destroyed by the diamonds
process and cannot he reared afte c Nb r mmn.
1111 NNe nereny aulnorize (�mmN P' V
jMsjQ Wcr&dmWWs
remains of Me deceased.
FINAL DISPOSITION
The person authorized to receive Me cremated remains ohe deceesad from the crematory is'.
Name: Baker Ful Home Parrionnal
Address 11 Lzifisrafte ittreart Qn.aurnal New Y A 128M Phone: (518) 981-93O3
The cremated remains of dewed wall be disposed of as 101MAS:
Rehm to family to be decided
N far any reason the person named above does not take possession of Me cremated remains.
rnwne>•x�w+wl P' U C M s authoraed ad Wine possession of Me remains to
Puroerlo re�.rrel Baker Funeral Home by delivery in person or by original mail.
{/A� MO e"
%ula..oas-to .01ne) w—mor zaN Ppe3 W]
fefdar the ounw,all)
YY rWJe undersand Mat Ktbe remains are not dismal contain 120 days of cremation.
j,,__pm Vim C may dispose MMe remains in an instrievable manner.
such as W scattering.
CREMATION CONTAINEWURN
(ndlel QYE of(he fedlou+ny
An um to be used as a container for the cremated remains has been purchased from
Sailer Funeral Home and is describetl as follows'.
beds undemfantl Met ttme um is foo small m hakl Me entire uamrted remeim, an atlditional rgid container may he used
for delivery.
.OR-
(nM . An um has not yet been purchased Me understand Mat if no um Is purchased or otherwise prow ded
r� 'Om, p V ato will place the cremated remains in a NO temporary
containerfordelorery.
This Authorization Foon was provkled by suwYTyurnmy
was executed at(u vii +w. ) RakeF IFb
rsmm+ ,a cu, 11 L few m move O sbu N Y rk 12g04 anti o signed by the draial director
as Witness to it e%eWOon.
I J have recened a completed copy of this Authorization Fops.
The sereonns) identified below Islam Me person(s) in co arel of disposNon,who by signing his Authorization
Form, antesgs)M the accuracy and completeness of the information contained in this Authorization Form and
authOrtrols) the foregoing.
Signed thin OIL day of pAkyiA . 202. `
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