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Laverty, Anna Pine View Cemetery 8• Crematorium Quaker Road Queensbury, NY 12804 (5 1 8) 745-4477 or (51 8) 745-4476 FUNERAL HOME: _.__._ .. RETURN TIME: DATE & TIME REMAINS ARRIVED AT CREMATORY: NAME OF FUNERAL DI►2ECT-UR OR REGRISTERED RESIDENT '��� DELIVERING REMAINS; rut NAME: 1.7N-'"._.F.l tAlitZri CASE II Jolt' TYPE OF CONTAINER: iJft‘iC. 61k, .... .44.42 tr/t te PLACE OF DEATH: ...... . .._3I_.....__._fzes ...... ._. 611— 5J ESTIMATED WEIGHT OF REMAINS 8. CONTAINER PLACED IN HOLD: - / PLACED IN REFRIGERATION: ........... .......__ .----._.._.._..._---•- DATE OF CREMATION: if) g' TIME STARTED: /':Zt? S _....___..__............._. _. ........__...._TIME COMPLETED: � �'J1' ./� J 11 PLACED IN RETORT: ��; ZS1 . ---- ---- -- rI _..... MOVED: ... 12 i0f. IZ 4S `Vat .......... _ RETORT If IN WHICH REMAINS WERE CREMATED; DETAILED REASON FOR DELAY IF REMAINS WIRE CREMATED MORE Re THAN 48 HOURS FROM TIME OF ACCEPTED DELIVERY: NOTE: THE CREMATION LOG SHALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATo♦ZY, n 10f0512020 02: 59 174=13730102 THEUPSSTORE . PAGE 02/05 New York State aepa ent of State N EW YORKotVISION OF CEMETERIES STATIOF Division One Commerce Plata OPPORTUNITY, Cemeteries 99 Washington Avenue Albany,NY 122 3 1-0 0 01 Telephone:(Sts)474.6 26 www.do5.'y,cov Authorization for Cremation and Disposition This Authorization Form must be completed and signed prior to delivery of remains for cremation. October 4,2020 l o 8 y w — Dater Number. Crematory Name:Pine View Crematory- Address;21 Quaker Road,Queensbury,NY 12804• Phone: 518-74S-4477 CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS. Cremation is carried out by placing the remains of the deceased and the container hotdin0 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 metal, which are all that will be left after cremation. Following aemation,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 wit likely be left behind. The crematory will separate incidental and foreign material from the remains end the incidental and foreign material wit be disposed of as required by law The cremated remains will be mechanically pulverized into smell pieces and placed into a designated container or urn. Cremated remains generally are pulverized until no single fragment is recognizable as skeletal tissue. OPENING ter THE CONTAINgR 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 or to ensure that no material is enclosed which might injure employees or damage the crematory property. if human remains are delivered in a container which is not suitable for cremation such es ceremonial or rental casket,the crematory will require that the remains be moved into a suitable container before it accepts the remains. The opening of a container or the transfer or removal of remains will be conducted before a witness and wilt be done in privacy,with dignity and respect. iDENTIFICPTION QF OJ CEASED Name of Deceased:Anna Laverty _ Marital Status: Divorced 31 First Street,South Glens Falls,NY 12803 w Last Know:Address: -�-- . Place Death 31 First Street,South Glens Fats,NY (1,q0 Sex: ©ul ®F Aga: 7 DOB:01/1 Q/1.963 Date of Death:10/02/2020 Estimated weight: 160 Description of casket/container in which remains will be delivered. Minimum Cremation Casket, Florence Casket Co. Cardboard/Pine PERSON IN CONTROL OF DISPOSITION (Pereon(ss)in control of disposition,inrgia!ONE of the following) - t--r-- I amMle are the designated age nt of the deceased designated in a will or written instrument executed pursuant to Public Health Law Section 4201. Off``/ imo have no knowledge that the deceased executed a written instrument pursuant to Public Health Law Section 4201 or a will containing cireciions for the disposition of his or het remains and I/we are the person(s)having priority under Public Health Law Section 4201 and have the right to authorize cremation of the remains of the deceased. My/Our relationship to the deceased Is as follows: Anna Laverty (Name 1'Deceased) -- DOS-1898-f(Rev.04/20) Page 1 of 3 _ 10/05/2020 02:59 17403730102 THEUPSSTURE PAGE 0?/06 Authorization for Cremation and Disposition enserf from the fist below) Number 5 Description: Any surviving s,bling eighteen years of age or older • 1. A person designated in writing pursuant to Public Health Law Section 4201(3), 2. The surviving spouse; 2a. The surviving donate partner: 3. Any surviving child eighteen years of age or older; 4. A surviving parent 5. A surviving sibling eighteen years of age or older, 6. A lawfully appointed guardian; 7. 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 duty appointed fiduciary of the estate. 9. A,:lose friend or relative who has executed a written statement pursuant to Pubic Health Law Section 4201(7): 10. A chid fiscal officer of a county or a public administrator appointed pursuant to the Surrogate's Court Procedure Act; 10a. Any other person who is acting on behalf of the deceased and who has executed a written statement puteuant to Public Health Law Section 4201(7). r.( f�9 LL THREE of the following) IMle hereby affirm that the body of the deceased does not contain a battery, battery pack, power Cell,radioactive Implant, or radioactive device and that any such materials were removed prior to the execution of this Authorization Form. Failure to remove these prior to cremation may result in harm to the crematory and crematory personnel. IM)e affirm that instructions have been given to Stephanie A.Gilman — 'rFurneroOtteacorNernei regarding the removal of any personal property or other thing of value which any person signing below or any family member of the Pine View Crematory deceased wishes to preserve. __ __. rC,enaa ev Marion is not responsible for the removal of personal items from the container or from the remains of the deceased. Personal items left in the con or with the remains will be destroyed by the cremation process and cannot be retrieved after cremation.IV t1We hereby authorize Pine View Crametory _ (Crematory Naae) to cremate the remains of the deceased. (Ini_jd OPTIONAL) 1/we hereby authorize the named funeral director to provide for delivery to and cremation by an alternate crematory,if deemed necessary in the opinion of the funeral director,and to amend this form to provide the correct name and address of such alternate crematory. • FINAL DISPOSITION The person authorized to receive the cremated remains of the deceased from the crematory is; Name: M.S.Kilmer Funeral Home Address;82 Broadway,Fort Edward,NY 12828 Phone. 518-747-9266 The cremated remains of deceased will be disposed of as follows: Mali to St.Michael's Cemetery,Springfield, MA for burial If fo'any reason the person named above does not take possession of the cremated remains, Pine View Crematory is authorized to give poss9SSion of iceeleeemme the remains to MB. Kilmer Funeral Home by delivery (Purest Notre Alone) in person dr by registered malt, Anna Laverty _ everecreeeeme DOS-1898-f(Rev.04/20) Page 2 of 3 - . 10/05/2020 02: 59 1;'40:37:3010'2 THEUPSSTORE PAGE 04/0E, Authorization for Cremation and Disposition (initial oliowing) INWe understand that If the remains are not claimed within 120 days of cremation. Pine View Crematorymay dispose of the remains ei drama or c(n?et n1`— .. an irretrievable manner,such as by scattering CREATION CONTAINEf3lURN Unfits!ONE of the following) An um to be used as a container far the cremated remains has been purchased from and is deserted as follows: • INVa understand that if the urn is too small to hold the entire cremated remains an additional rigid container may be used for delivery. -0;4, • An urn is not yet purchased. Ir',Ne understand that if no urn is purchased or otherwise provided Pine View Crematory will place the cremated remains in ;Nameacrerratrry? a rigid temporary Container for delivery Stephanie A. Gilman .v This Authorization Form was provided by was ex t e 'ta f,ca rr (Roe*Oinactoveivre)M.B.Kilmer r uneral Home 82 Broadway,Fort Edward,NY 12828 n ((unrai Nome and is signed by the funeral director as witness to its execution, • be Me have received a completed copy of this Authorization Form. r7 F\i c (1. [' LC)/:a'. The persons)Identified below is/ere the person(s)In control of disposition,who by signing this Authorization F a ) Gs, to the accuracy and completeness of tha Information contained In this Authorization Form and authorlee(s)the_ s. Signed this 54� day of_- _ _,20 20 • i Ty edaPrnret/Name s� 105 Cornerville RD,Marietta,OH 45750 "'�„rrrs s10„` Aearoes >> or�eirranramo 1_�"aaurt _ • AbG+ess TygdorPr6,ieaNana --,--- ^"— Siprefure — WITNESS: • r , Miner&a:War Types aPknad Name! lRMaie7 rl✓ecar 5iyreumtl LtiIL2 • (R/4a1rarar rw,sga) Anna Laverty i Paine m our a e.v) DOS-18efef(Rev 04120) Page 3 of 3