Kelly, Kathie Louise Pine. View Cemetery m.�
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QLIe011S1)Ury NY '12804
( 5 .18 ) 145-141 7 or (5 -10) 45 4176
rUNCRAI HOME:
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E R[ MAINS ARltivf u
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SI[7EN I I>ELIVEItINO REMAINS:
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TYPE OrCOrJ Cl15f; rJ IZ�Z
t AIN(-ft: 3u�-�Clo
PLACE ofLr�{ �� t
DEATH: 10 lc,ft) 'ur
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ESTIMATED . .
WEIGh1 1 (Uh REMAINS - .
CONTAINER _._..
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PLACED IN HOLD: ._._...... fib '
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LACED IN rtr►=RIGE,. ATION;
DATE .. ._
Or CR['MATION:
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TIME ._....._
START
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PLACED IN L TOrt t 1.7601
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MOVED: 2:�
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Ch) Itf MAINS W
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DETAILED REASON f= -. ...._
nR DELAY IF ltl=MnINS U�l:ltl_: �.....__.
CLtGMATEO MORE THAN Alt} HOURS
FROM TIME or AC;CEnTE0 f)T:LIVERY;
. ...... ...
NOTE:
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lMF1 I ION LOG srinl,l ... ...._.....-. _
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�,f —NEW YORK 1 Division of DIVISION or CENII ffptf'�
STATE or
OPPORTUNITY Cemeteries :r
Authorization for Cremation and Disposition
This A unto filiation Form must be completed and signed prior to delivery of remains for Cremation
oat. - _ 11/30/2020 Number IZ I,Z
Crematory Name Pine View Crematory
Aridness;Quaker Road,Oueensbu y,NY 12,004 Phone (51tD.,745-4476
crentatiCali IATION If AN lRRIYENDIILE AND DL RO CESS, - __-- -- - -
is carried out Ilia Pial IIQ ttie remainsIA of thPe deceased end the conts.ner holding the rermaw e Into a cremation chamber whereI
*of are I bj.CRad to intent*Beal and flame, The heat and flame wilt inclneratet and consume everything sm:ept bone and where
which are all that will be left atter cremation.
Following crematon.Me orattiatory will take reasonable aliens to remove sit of the remains and other material from the cremation
ahember,but some minimal dust and residue wit likely be lea behind. The crematory will separate inodentai and foreign material from
Rteworrains and the incidental and foreign material eel be disposed of as requited by law. The cremated remains wi l be mecttanicai%y
pulverized into small pine*and.pieced ItJO a designated container or urn Cremated remains generally are pulv.rf ed un no
fragment is rsgognl bla as skeletal tissue.
t
!►may Wetopen ilia conMitfler holding the utrcremated human remains in limited circumstances,such as to confirm the
-identity tithe deceasedatt4 ensure that no maNtal fs Might injure employees or damage the crematory property E
of t delvarsillet a aoetsicer i rX r cremation such as ceremonial or rental casitet,the
i .1e��the remains b 3 t t ' `a { It accepts�remains. The opening of a
4, or tantr tqN etrttittairis i ° and we be titan*in pmraey,with dignity and respect
-1 1 .!,, ‘
a macawStatus. Married
I 1: a1 z `
•
� - 130
17 1 boa a ` .t.- '' i !r ' Estimated Weight LBS
} Container
r ,y et tlfa deceased designated the will or ttsti11art
$ e! t i • a 1 '' a Wf a- y.
"4 t`"' t t ' : ...' _-sr , 4 r ' and 1/W! �t ts) tP�Y ,
� r,,.,, _ <tsmains of%NJ itece d. MyIOur relationship
Ye r
3 "' Kathie Louise Kelly
t d.'ecit?rceas+dt
Dt�1898-f(Rev. 04/20) , 3
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i
TIIIIIIIIIIIIIIIIII711111.IIIIIIIIIIIIIIIIIIIII"1"..."Authorization for Cremation and Disposition 111111111.11.1.1.11
s.'rt freer the list below)
mber _ 2 Description'Spouse -------
A person designated in writing pursuant to Public Health Law Section 4201(3)
The surviving spouse;. The surviving domestic partner.
Any surviving child eighteen years of age or older,
A surviving parent,A surviving sibling eighteen years of age or older.
A lawfully appointed guardian;
Any person(s)eighteen years of age orolder entitled to share in the estate and who is/are closest in relationship to the deceased
A duly appointed fiduciary of the estate;
A close friend or relative who has executed a wnttenstatement pursuant toPublicHealth LawSection 4201(7),
A chief fiscal officer of a county or a public administrator appointed pursuant to the Surrogate's Court ProcedureAct.
. Any other person who is acting on behalf of the deceased and who has executed a written statementpursuanttoPublic Health
Law Section 4201(7)I ALL THREE of the following)
I/We hereby affmm that the body of the deceased does not contain a battery,battery pack.power cell,radioactive implant.
ioactive device and that any such materials were removed prior to the execution of this Authorization Form. Failure to remove
items prior to cremation may result in harm to the crematory and crematory personnel.
XI/We affirm that instructions have been given to Mark J.DeSimone
(fenere/D+vela 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. Pine View Crematory
townwow wing
is not responsible for the removal of personal items from the container or from the remains of the deceased. Personal items left In the
orwitlt.tt?re remains will be destroyed by the cremation process and cannot be retrieved after cremation.
we-hereby authorize Pine View Crematory
R to cremate the remains of the,deceased.
. (Initial OPTIONAL)
tlwe hereby authorize the named funeral director to provide for delivery to and crem . , Mt t�
if-deemed"necessa_ in the opinion of the-funeraldirectoi a d'to „- ".m.z. .na
�rY, A r! P r n >lrnend this to rts t l>._._t 4_ na and
address of such alternate crematory.
11 �'-• ° ••. '�• -.._ "�1!-, Li TIT,- i..� !``, C .F�,.li t , r3' .I)�:,. �` ,.
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.Etta i ,�? r'` .�;" �4 L.,
Authorization for Cremation and Disposition
(In�il(�ra_�+�/�he/olfowin91
4� lANe understand that if the remains are not claimed within 120 days of cremation,
Pine View Crematory
an irretrievable manner,such as by scattering IN..ac ,aoyi — ___may dispose of the remains in
CREMATION CONTAINEanJRN
(h_litig ONE of the following)
An urn to be used as a container for the cremated remains has been purchased from Eingleto uSulllivan Potter
and is described as follows:
INVe understand that if the urn is too small to hold the entire cremated remains,an additional rigid container may be used for delivery
-OR-
Lr— An urn is not yet purchased. IfWe understand that if no urn is purchased or otherwise provided
Pine View Crematory will place the cremated remains in
(Name of Cremelory)
a rigid temporary container for delivery.
This Authorization Form was provided by Mark J. DeSimone
was executed at
(Funeral Dom inn'Nome)
Singleton Sullivan Potter Funeral Home
(Fun,,.Hann Name)
407 Bay Road, Queensbury, NY 12804
(Funeral Herne Address)
and is signed by the funeral director as witness to its execution.
INVe have received a completed copy of this Authorization Form.
The persons)identified below is/are the persons)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 authorizes)the foregoing.
Signed this 30th day of November ,20 20
George U. Kelly- Husband
Typed or Phnred Name
143 Brand Hollow Rd, Plattsbugh, NY 12901
Address
typed or Pealed Name Sprurwa
idd ass
mod or PenlodNamo Slpnafuro
*tow
aTNESS:
rTh PQ
Mark J. DeSimone
metal Okada Typed or Printed Name) (Funanl0aector al
10919
Iyaff hOn M,nbe i
Kathie Louise Ketty
(Neat of Deceased)
)S)f. 898 t(Rev. I