Kaiser, Gary Lyle Pimc, ly'(.�vv Cem2terV & [rorn,�atox,,Ionm
C>uaker >�0ad
Qu(-,,@nsbury. NY1280/1
(518 } 7 or /516> 745-44-76
FUNERAL *0vxe
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New York State
Department of State
titW YORK Division of DIVISION OF CEMETERIES
er—
STATE OF One Commerce Plata
_ 1PPORTNNITY. Cemeteries 99 Washington Avenue►
Aiba►yy,NY i2291-0001
1elephore:(51e)474622e
www dos ny.gov
Authorization for Cremation and Disposition
This Authorization Form must be completed and signed prior io delivery of remains for cremation.
Dats:Octobet 28.1020— Number: !-(� I
Pine View Crematory
Crematory Name:
Address:21 Quaker Road. Cueensbury, NY 12804 Phone:51844544771,
CREMATION 1S 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 wiN incinerate and consume everything except boas and Metal,
which are all that will be left after cremation.
Following cremation,the crematory will lake reaaanabie efforts to remove all of the ruins and atlas material Inge the Cremation
chamber,b..0 some minimal dust and residues will likely be left behine. The crematory et separate inch er.tai and foreign motorist from
the remains and the incidental and foreign material wilt be disposed of as required by law. The cremated remains will be mechaniceily
pulverized into small pieces and placer into a designated container or urn, Cremated remains gsrerelly are ps Iverired urea no
single fragment is recognizable as skeletal tissue. .I
9PENING OF THE C9NTA1w)"R.
The crematory may only open the container holding the urt-cremated human remains in limited circumstances,such as to confirm the
identity ci 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 cer.moniel or rental casket,the
crematory will require that the remains be moved into a suitable container before it accepts the remains.i The opening of a
container or the transfer or rerrovet of remains vvlii be aand,scted before a witness and witi be dorm in privacy, dignity and respect,
tretcriFf..R
Name of Deceased:Gary Lyle Kaiser —`— _A--� Marital Statue.Married
7E Alpine Ave.,Queensbury,NY 12804
Last Known.Address: _ —�._
i
Place of Death:76 Alpine Ave,Queensbury,NY 12804
sex: i i lA C]F Age:70
L. _ DOB.7/2311950 Dataof Deeti,.1O126/2O20 Estirnated weight: 185
Descriptor of casket/container in which remains wail be delivered.
Minimum Cremation Casket, Florence Casket Co, cardboard/pine
Pf RSON cONTRQL.OF DISPOSITION
(Parson(s)in contra!of disposition, init.g!ONE or Me ier'lvwinjg)
I am/We are the designated egert of the deceased des gnated in a will or written instrument executed pursuant to Public
Health Law Section 4201.
-
I
have nof knowledge that the deceased executed a written instrument pursuant to Public Health Law Section~4201 or e
Ni containing directions for tine disposition of his ar her remains acid Siva are the persnm(s}having priority undsi P Spain tiaatth Law
Section 4201 and have the ng`1t to autrorxe cremation of the remains of the deceased. MyiOur relationship Id the deceased is se
follows
Gary Lyle Kaiser
- .._..
,ip a(wawa)
OQS-188E-f(Rev.04120) Page 1 of 3
I
a5ed 9A9896691L P 9ZtrN red dH Nd9F170 Q?OZ 8Z PO
Authorization for Cremation and Disposition
(Insert from the list below))
2 The surviving spouse _ _ --
Numoer DebGription:
1. A person designated In writing pursuant to Public Health Lem Sector 4201(3):
2. The surviving spouse;
2a. The surviving domestic partner
9. Any surviving child eighteen years of age or older;
4. A surviving parent:
5. A surviving sibling eighteen years of age or older
d. A lawfully appointed guardian;
7. Ary person(s)eighteen years of age or older entitled to share in the estate end who islare closest In reiatiarkshie to the deceased;
e. A duly appointed liduciery of the estate:
9. A close friend or relative who has executed a written statement pursuant to Pubic Health Law Section 4201(7I;
10, A chief fiscal officer of a county or a pebiic adr'irtisirator eopnirted pursuant to the Surrogates Court Procedure Act;
10a. Any other person wino is acting on behalf of the deceased and who has executed a wetter statement pursuant to PuDNc Health
Levi section 4201(71.
.~.1.THREE of the following)
ItWe.hereby affirm that the body of the deceasee does not cerise a battery. battery pack,powe
r cell,tadioective implant,
or radioactive device and that any such materials were removed prior to the execution of this Authorization Forme Failure to remove
ih time prior to cremation may result In harm to the crematory and crematory personnel.
r Stephanie Gilmer
iI+1 fat firm that instructions have been elver to ,Trmee fi r K+;se
regarding the removal of any personal properly or other thing Cf value which any person signing below or erry family member of the
Pine View Crematory
deceasee wishes to preserve. ___ rc.m.rory Name;
Is not responsible for the remove!of personal items from the container or from the remains of the deceased. Pertional items left In the
container or with the remains will ha destroyed by the cremation process and cannot be retrieved after cremation.
` , P!ne hliew Crematory -- f
�j' a hereby authorize (t4mstMk rra,1
to cremate the retains of the deceased.
I
oval I OPTIOfVAL)
^„_lfwe hereby authorize the named funeral director to provide for delivery to and cremation by a,Altercate
crematory,If deemed necessary in the opinion of the funeral director,end to amend this form to provide the correct nevi end
address of such alternate crematory.
FINAL D18POSITION
The person autecrized to receive the cremated remains of the deceased from the crematory is:
Name:M.B.Kilmer Funeral Home .—
Address:82 Broadway;Fort Edward, dt' 12825
Fnane 518 7a7-826i1
The cremated remains of deceased wilt be disposer!et es follows:
Place in Columbedurn Wel!al Gerald See.Solamar Saretega Natlanel Cemetery
---_---- -
If for any reason the person named above does not lore p
oseession of the cremated remains;
Pine View crematory —_—_—- __....__------- le authorized be give possession of
—_ I
ce,weeee Ne"et 1 _by delivery
the remains to M:6.Kamer Funera3 Home — .-
—
Am•ret tkms NNn1)
In person or by registered mail, Clary Lyre Kaiser ___
Nem.oro �l.a.+ —
1 Pag18 2 013
cos tags t Rey.aat �ti i
Z abed 9y98c669 iL 'u2r9ZtrN xed dH ivdd9€ltrC OZDZ Rai '.=.)0
Authorization for Cremation and Disposition
atitei the foltox?og)
I.We understand that If the remains are not claimed within 120 days or cremation,
Pine View Crematory
_____._.___._ —_ _.____rrsy dispose Of the remains in
;Nero*or Cmfrakr g
an irretrievable manner,such as by scattering.
gR£MATIIONSzONTAJNERAIR F(
((n ifiel ONE of the following)
An urn to be used as a container for the cremated remains has been aurchased from __
erd is described as fogowel --- —_
Uwe understand that if the urn is toe small to raid the entire cremateC remains. an acditionat rid conteine•may be used for delivery.
I
-OR- Y
Gin Is not yet purchased, iMIs understand that if no urn is purchased or otherwise provided
Pine View Crematory will place the a emaaated remains in
*Norm a YrwitrlaY:
a ngiC temporary container to delivery.
Teats Authorization Form was provided b} Stephanie G,lrnan _ ,,_was executed at
{Fun*41 Do".A.'Narm
M.S. Khmer Funeral Home --
+f my*.Marrs.AWNie
82 Broadway,Fort Edward,NY 12828
(Floral MOM AWiresal
and is signed by the funeral director as witness to its execution.
tNve have received a completed copy of this Authorization Form,
The persons)identified betow lslare the person(a)in control of disposition,v*o by signing this Autfroriz flan Form,attest(s)
to the accuracy anti completeness of the information contained in t is Authorization Form ar`d authoeize a fotWWitg.
Signed this 28th day of October .20 20 •
Dolores Kaiser
'two ar PM&*Moe 'g�erurz
.. k.m. —' s,on,>rn ..__ - _----- ______ —
Argare
address �._...��_
j
WITNESS;
Stephanie Gilman r a,%,—, A
Ps�aod runs. r i,ia r sgn,rvr!)
rliryo�r tlorrsfor nisi Dii
14163
ritin. s ) f
Gary Lyle Kaiser
----Twin.eI oeow*eo, --
DC3S-189134(Rev.0412C) Page 3 of 3
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E acted 9y9856691.2 Jp;97.t'N red dH WciL017O OFOZ 8Z 1=0