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McCormack, Patrick J. Pine Vic Cemetery 8, CrLm,:)toriufn Quilker 1<oac1 Queen S1.)ury, NY -1 2804 ( 5 •1 8) 745-4141../.7 or ( 515) .145` 41 7 6 rUNCRAL, HOme.: PENswic PIE DATEQ TIMERE rURN TIMr-. I M AI S ARrely ............ . LU A ► f.rtt:: M!\ IUItY: / NAME OF rurvEfznl. fllrtt_c ('OR nrt 1«cl(I ,.. ., . tZllt ►rmAiN Tl..lt[`(� 111_SIDrN r (>El IVEF2ING RAM S._.._. Srutbl'tik AINs: . . NAME: .._. ftML nClocr CON TYPE OrCAJtr JJ 12Ll rntr(crr: ('1c.4{y4_ ‘ C/ PLACE OF DEATH: yy (it r 4., oaf . C 1. (t;r,tf'. tit/ 17$/z . ESTIMATED LU WEIGHT IGr-t'i OF REMAINS 8. CONTAINER PLACED IN HOLE): ?Op 23oI�c PLACE() IN r(r►-►-ZIGERn'rION; P ........ ....... z 1 ' 1 ATE OF CU MATION: /2 hi IZa TIME: STARTED: ON 1-nR PLACED IN R� f orz f .._- .......... RCTOtzr II IN WrIICIt ItL MAINS w CRF CI( MATED. yh �� DETAILED IZf�A: . 'TWL'�"_. .al�� __......__ > OFLAy II IZI=M/lSN .; U.ir:tit:: PTr_o or:LivertY c ItC MAT( D MORE THAN qp HOURS TIME or ACCF .... .............. TUC .... C111Mlll iON ...... NOTE: r ......__.. SMALL 1 f. tt tti T nIN,I-1) IN Il( P[IiMll Pl l.iN T� ITIC_L' Or 'Nit' (;It(;nnn7U(l Y, New York State Department of State TX-NEW YORK Division of DIVISION OF CEMETERIES STATE OF One Commerce Plaza OPPORTUNITY_ Cemeteries 99 Washington Avenue Albany,NY 12 2 31-0 0 01 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. 12/03/2020 Date: Number. I-19 Crematory Name:Pineview Crematory Address:21 Quaker Road,Queensbury,NY 12804 Phone: (518)745-4477 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: Patrick J. McCormack Divorced Marital Status: Last Known Address: 44 Chapman St.,Corinth,NY 12822 Place of Death: 44 Chapman St.,Corinth,NY 12822 Sex: ®M OF Age: 67 DOB: 02/02/1953 Date of Death: 12/02/2020 Estimated Weight 200 lbs Description of casket/container in which remains will be delivered. (type/materialImodel/manufacturer) Matthews Aurora Wood and Cardboard Cremation Container 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- • M INVe have no knowledge that the deceased executed a written instrument pursuant to Public Health Law Section 4201 or a will aining 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. MylOur relationship to the deceased is as follows: Patrick J. McCormack (Name ofDeceased) DOS-1898-f(Rev.08/15) Page 1 of 3 Authorization for Cremation and Disposition (Insert from the list below) Number: 5 Description: Surviving Sibling 1. A person designated in writing pursuant 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; 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 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 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 pursuant to Public Health Law Section 4201(7). (Initial ALL THREE of the following) M (,/ I/We 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. MI/We affirm that instructions have been given to Robert Densmore (Funeral Director Name) regarding 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. Pineview Crematory (Crematory 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 will be destroyed by the cremation process and cannot be retrieved after cremation. rIIWe hereby authorize Pineview Crematory (cremator Name) to cremate the remains of the deceased. FINAL DISPOSITION The person authorized to receive the cremated remains of the deceased from the crematory is: Name:Robert I.Densmore Address:7 Sherman Avenue,Corinth,NY 12822 Phone: (518)654-9285 The cremated remains of deceased will be disposed of as follows: Sent to sister in Ireland If for any reason the person named above does not take possession of the cremated remains, Pineview Crematorium is authorized to give possession of (Crematory Name) the remains to Densmore Funeral Home,Inc. by delivery (Funeral Home Name) in person or by registered mail. Patrick J. McCormack (Name of Deceased) DOS-1898-f(Rev.08/15) Page 2 of 3 12/3/2020 1607010027081 Authorization for Cremation and Disposition .y1FAyMIiM agAd Ihtl ftltrowing) IAN undersfr d that It the remains are not chimed within.120 days of er+amation, ► VI"Crematorium ' ...,.... __may d+b0a5R 7f the r$rr}attt$tfi tr�+ilhainrabltl mariftar,KM as by acmiering Y k { . 3 t•l:'Y�,tt it"!r l ill. !D ba sad*LA oDnlaIn er for the aenreted"tin** hse p4�►gf�8oecf fitrtn per�stnore Fr.+nt of Home tnt r 1� Oak urn �,,t. , . IFt a urn is too small to hold the entire cremated r en edam* n rrray t�wed ion t + y s . r f 4 his net purchased, UWe understand that it no urn Is purchased or Pr �� , a ,y� uvKied+fit piece re grated zer^ s ` , l' '- , _ for dslively � ' Robert I.Densmore s !frotm Web provided by ..' _. s r (Pw�uawepaNamr) w3 ereU'__3 3w !' orInth.AIY 12822 ¢awe+mmrtWlaesj r'�s e fit` " #erai director as witness to Its execution. Mumma Nano*dam" , _ -, • completed copy of this Authorization Form. u ' ,� ''''' 'below lsiare the persons)in Control of disposition,who by signing this Au florfration Form.atsestts; r and cgmpletenass of the information contained in this Authorization Form and ar#►orize(sy the foregoing_ % : #a s .5 1`` - December 20 day r Zo . srt " Meath.Ireland, A82VZD1 /V//VD/// zFA. ,as' 0 i 'x z f F' 4 d t 4. g Patrick .I, McCormack pftiretratesaisof fi � Yy Page 3 of 3 '• _ -s https://mail.google.com/mail/u/0/?tab=wm&ogbl#all?projector=1