DeCristofaro, Michelle J. Pine View Cemetery 8, Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME:
RETURN TIME:
DATE 8. TIME REMAINS ARRIVED AT CRCMAIORY:
NAME Of r
FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
MAIAI
NS:
NAME: _..- _.._
Icwate Pf C (z/ srofIInp,Q�
V_
.._ CASE rr �ro6
TYPE OF CONTAINER:
PLACE OF DEATH: jSZ...........__-_ Siwl�1 ✓ � flog
d S4rv44iet 1614- 0$76
...............
ESTIMATED WEIGHT OF REMAINS & CONTAINER. .
./_.375.1br
PLACED PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION:
/��j
TIME STARTED:
1... --..
__........ ..... ....__ .._... ..... 1 TIME COMPLETED: I,3tr. n
PLACED IN RETORT:
---....._.__........_I � MOVED:
' ' {...T 11
........-...
u I' .l_ a
.................
RETORT 11 IN WHICH REMAINS WERE CREMATED: LS .
DETAILED REASON DELAYFOR .
IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OP ACCEPTED DELIVERY:
NOTE: THE: CREMATION LOG SHALL. riri RL FAMED IN THE PERMANENT FILE OF THE CREMATORY•
•
New York State
N EW YORK Department of State
Division of DIVISION OF CEMETERIES
STATE OF One Commerce Plaza
OPPORTUNITY_
ORTUN 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: /n/►3/Z p Number. /106
Crematory Name:Pine View Crematory pp'' �/1�
Address: it 0 01,} l �0� tll €E I ! r' Phone: 61 g') c-Yti
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 w)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: m c1}e. -/e, lir— Q e F,.; j. -e& Marital Status: 1970 P J'I e4.„„.
Last Known Address: /-6-.2!_Z ie P,i eI Ls 3 J v›rm d I ay f G
Place of Death: 1.5�. S W ee,ly roe tit L J\
Sex: 0 M L F Age: "70 DOB: 0 -a/_ T 7 Date of Death: /d/4d101o02d Estimated Weight (,2 jd
Description of casket/container in which remains will be delivered.
..c2 _ u)ott /1 - O s l
PERSON IN CONTROL OF DISPOSITION
(Person(s)in control of disposition,initial ONE of the following)
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:
c elk Oe s'i-j,sThF ecr-O
DOS-1898-f(Rev.08/15) Page 1 of 3
Authorization for Cremation and Disposition
(Insert from the list below)
Number:_A-Descriptiorr7ji JNS1. A person designated
L The surviving spouse;
tO wiling pursuant Public Health Law Section 4201(3);
3.2a. The surviving domestic partner,
4. g pasurviving
rent
eighteen years of age or der; •
8. A surviving sibling eighteen years of age or older;
8. A lawfully appointed guardian;
7. person(s)eighteen years of age or older entitled to share in the estate and who is/are closest in to the decease(
duly appointed fiduciary of the estate;
9. A close friend or relative who has executed a written statement pursuant to Public Health Law Section 4201(7);
10. A chief fiscal officer of a county*re public administrab�r ad to the Surrogate's Court Pip 0
Any other person who Is acting on behalf of the deceased and who has executed a writ sn statement pursuant to Public Health
Law Section 4201(7).
(Initial ALL THREE of the following)
Me 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 Items prior to cremation may result in harm to the crematory and crematory personnel.
UWe affirm that instructions have been givers to :11--- A-) 1-C•mi
r 1i negarittr 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 Crematory
(Caemsby Name)
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 wilt he destroyed by the cremation process and cannot be retrieved after cremation.
. 1/We hereby authorize Pine View Crunatory
ra.nsro►y ►
to cremate the remits of the deceased.
FINAL DISPOSITION
The person authorized to receive the cremated remains of the deceased from the crematory lac
Name:Any Staff from the Edward L Kelly Funeral Home
Address:1019 US Rt 9 PO Box 548,Schroon Lake,NY 12870 phone 51&b32 7177
The crenated retrains of_deceased will be -of as follow-.
q6,9 ktc. h i c i< s r-
13oh-er ; A j 1l7/
If for any reason the person named above does not take possession of the cremated remains, •
Pine View Crematory
is authorized to give possession of
Camakryliang
the remains to Edward L Kelly Funeral Homeby delivery
[Freed Memo Naas*
in person or by roistered mail
n1/c A e I/a i -lws Po F ,"
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00S-18984(Rev.08/15) Page 2 of 3
Authorization for Cremation and Disposition
(Initial the following)
Me understand that if the remains are not claimed within 120 days of cremation,
Pine View Crematory
may dispose of the remains in
~mot Cremato6/
an irretrievable manner,such as by scattering.
CREMATION CONTAINER/URN
(Initial ONE of the following)
)') An urn to be used as a container for the cremated remains has been purchased from Edward L Kelly Funeral Home
and is described as follows: g , pAs- e
INVe understand that lithe urn is too small to hold the entire cremated remains,an additional rigid container may be used for delivery.
-OR-.
An um• �ot
yet aset d that if n is ed or se l d
arQ m
v will place the mated remains in
a rigid temporary container for delivery.
This Authorization Form was provided byr, -i✓ was executed at
Edward L Kelly Funeral Home (Frmeral Horne Nan*
/
1019 US RL 9,PO Box 548 Schroon Lake,NY 12870
Fummemonyeacitheso
and Is signed by the funeral director as witness to its execution.
IIINe have received a completed copy of this Authorization Form.
The person(s)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.
Signed this /I )1 day of O C 4-e r� ,20 d—"
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DOS-1898-f(Rev.08/15) Page 3 of 3