Hillman, June E. Pix»�� Vic-vv C(_nn�terV
QuakerI�Oad
Queellsbury/ NY 12804
(51 B) 745-447'z 01. /518> 745-44-16
FUNERuiH0»xF.. �U
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_ ' RETURN
DATE & T|w�EREowNM� ARRIVED 4T ( ncxxAT �08Y ----------
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wES|0ewr DELIVERING
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NAME: w '°
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PLACE: OFDE/\TH.
DEATH:
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ESTIMATED wEZ|G+,r OF uExxA|mS o c0mTmwsn -------- --.....
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pL«Cro IN HOLD:
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DATE 0FCREMATION: -------------------
TIME ST -----
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RETORT o IN vv��/c�1 REMAINS vvcn� CREMATED: _ -�~=' ' 'DETAILED REASON KEAS{}N FOR DELAY IF: /<Exxx/wS vvsns cxs:x� -----'-------'
FROM TIME OF /���c�pTso DELIVERY: rsD MORE THAN 4OHOURS
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New York State
ent of State
rf-INEWYORK Division of DepartmEMETERIES
DIVISION OF CEMETERIES
STATE OF One Commerce Plaza
�J OPPORTUNITY_ Cemeteries 99 Washington Avenue
Albany,NY 12231-0001
Telephone:(518)474-6226
www.dos.ny.gov
Authorization for Cremation and Disposition
This Authorization Form must be completed and signed prior to delivery of remains for cremation.
Date: 10,5 170 Number. (°I i
Crematory Name:Pine View Crematory
Address: L I alp goAr0 Ovu0Ptiay nioy Phone: WO
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation is carried out by placing the remains of the deceased 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 metal,
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. Cremated remains generally are pulverized until no
single fragment is recognizable as skeletal tissue.
OPENING OF THE 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 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 as 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 will be done in privacy,with dignity and respect
IDENTIFICATION OF DECEASED
Name of Deceased: X We f. ///Z'/v/ , Marital Status: tOi CLmcd NC
Last Known Address:: is?; US iet9 Sc fl l li�p�e� /t.J j 7 G}
Place of Death: E( e-wc a Gr T;c aa1 de rc3 a i 17 co u d Q a. / ) '' ) 3
Sex: 0 M 5F Age: Z/DOB: ielci f fa Q' Date of Death: C a0a(J Estimated Weight: /VC f'O�Description of casket/containeerin which remains will be delivered.
1lCt'Wc-e Od. 1 r'ae �`o'►'1-/Joe,--
PERSON IN CONTROL OF DISPOSITION
(Person(s)in control of disposition,initial ONE of the following)
R E-D I am/We are the designated agent of the deceased designated in a will or written instrument executed pursuant to Public
Health Law Section 4201.
-OR
I/We 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 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:
d
DOS-1898-f(Rev.08/15) Page 1 of 3
Authorization for Cremation and Disposition
(Insert from t m list below)
Nummber Descriplort i 13 L//3 7 /a- (Ks
1. A person designated in willing pumuant to Public 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 yeareof age or older;
6. A lawfully appohted guardian;
7. Any person(s)eighteen years of age or older entitled to share in the estate and who islare closest in relationship to the deck
8. A duly appointed fiduciary of the estate;
9. A dose Mend or relative who has executed a written statement pursuant to Public Health Law Sermon 4201(7);
10. A chief fiscal officer of a county era public adrrrinistrabor appobited pursuant to the Surrogate's Court Procedure Act:
10a. Any other person who is acting on behalf of the deceased and who has executed ed a written statement pursuant to Public Health
Law Section 4201(7).
(Initial ALL THREE of the following)
gas' UWe hereby affirm that the body of the deceased does Ioontain a to 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 items prior to cremation may result in harm to the crematory and crematory personnel
R�-il uwe affirm that Ions have been given to f•144A-' Kalsolemi
Raw
regarcring 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. (Ilemetor,Ward
Pine View Crematory
is not responsible for the removal of personal Items from the container or from the remains of the deceased. Personal items left in the
container or with the remains will be destroyed by the cremation process and cannot be retrieved after cremation.
Il O UWe hereby authorize Pine View Crematory
(Ciamamr )
to cremate the remains of the deceased.
FINAL DISPOSmON
The person authorized to receive the cremated remains of the deceased from the crematory Is
Name:'4nyStaff
from the Edward L Kelly Funeral Home
Address:1019 US Rt.9 PO Box 548,Schroon Lake.NY 12870 Phones 518-532 7177
The cremated remains of deceased will be disposed-of as follow-.
SevekAli« ate-7 S'cireat 17$-7b
if for any reason the person named above does not take possession of the cremated remains,
Pine View Crematory
(CmmaboyAtomei is authorized to give possession of
the remains to Edward L Kelly Funeral Home by delivery
Ammo eommems
in person or by registered mail.
Amato-eoess-p
DOS-1898-f(Rev.08115) Page 2 of 3
Authorization for Cremation and Disposition
(Initial the Mowing)
Q UWe understand that if the remains are not daimed within 120 days of cremation,
Pine View Crematory
may dispose of the remains in
(NameofCrpnefory)
an irretrievable manner,such as by scattering.
CREMATION CONTAINER/URN
(Initial ONE of the following)
t 0 An urn to be used as a containersn for the cremated remainshas been purchased from Edward L Kelly Funeral Home
and is described as follows: A/NI li'A c
WVe understand that if the urn is too small to hold the entire cremated remains,an additional rigid container may be used for delivery.
-OR
An rs not rchased. i un d that if no um is purchased or otherwise provi
T 1)— " will place the cremated remains in
nor
a rigid temporary container for delivery.This Authorization Form was provided by L-t/t> , was executed at
Edward (Funeral rldBnle)
L Kelly Funeral Home
1019 US Rt.9,PO Box 548 Schroon Lake,NY 12870 ( r
ome
(Funeral Nome Address)
and is signed by the funeral director as witness to its execution.
UWe have received a completed copy of this Authorization Form.
The persons)identified below islare the person(s)in control of disposition,who by signing this Authorization Form,attest(s)
to the accuracy and completeness of the information contained in this Authorization Form and authorize(s)the foregoing.
Si ed this Slri day of C)C Qr------ ,20 .
KOLyitgroc-rid Q 1lels arYQ701 e_ kl/Y1 Ce,e4
Typed gr
13 ;rows)/ . 0(tieJl!/e_ I 1- 6 1� s 0
typedMane
arPrieed Name
Address
Typed or Plinted Name s
gnithwe
MOUS
WITNESS:
(Funeral Meat Typed or Printed , CriredorSI
we, CC, di // /tj
i of uwwizew
DOS-1898-f(Rev.08/15) Page 3 of 3