Mainwaring, Thomas Lloyd c... r e rn.-..1 t o i u n)
Pine View Cemetery ,,P
quit k et. i<0 ,71(.1
C4weilshury, NY 1 2.8041
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NEW PORK Department of State
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`' DMSIOEEY ���' ` �'� ` Ont Commerce Para
99 Washmgtori Avenue
Albany.NY 12231 0001
Telephone(518)474 6 2 2 6
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Authorization for Cremation and Disposition
This Authorization Form must be completed and signed prior to delivery of remains
for� cremation.
Date. 12/21/2020 Number 1 "
Crematory Name Pine View Crematorium
Address 51 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 tone and metal,
which are all that will be heft after cremation.
Following cremation,the crematory will take reasonable efforts to remove at of the remains and other material from the cremation
chamber,but some minimal dust and residue will nicety 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 tan. 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 properly 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■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. Thomas Lloyd Mainwaring Marital Status. Widowed
Last Known Address:20 Beekman Place,Queensbury,NY 12804
Place of Death.Home Of The Good Shepard,26 Rock Rose Way,Wilton,NY 12831
Sex. ®M 0 F Age. 92 Dog-. 08/25/1928 Date of Death 12/18/2020 Estimated ' t'/Se i b
Description of casket/container in which remains wit be delivered.
Alternative container—cardboard construction,no interior—Matthew's Casket Co.
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�
£IYl0. I e have no knowledge that the deceased executed a written instrument pursuant to Public Health Law Section 4201 or a
will containing rrections for the disposition of his or her remains and ltwe are the person(s)having priority under Public Health Law
Section 4201 nd have the right to authorize cremation of the remains of the deceased My/Our relationship to the deceased is as
follows
Thomas Lloyd Mainwanng
DOS-1898-►(Rev 04/20) Page 1 of 3
Authorization for Cremation and Disposition
(Insert from the list below)
Number 3 Description Child:-Eileen Odom
1. A person designated in wnting 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;
6. 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 m the estate and who islare closest in relationship to the deceased,
6. 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 7 erson who is acting on behalf of the deceased and who has executed a written statement pursuant to Public Health
Law Section 4201(7)
(In ral ALL THREE)1I the following)
CMe' I/We hgreby affirm that the body of the deceased does not contain a battery,battery pack,power cell,radioactive implant,
r radioactive device and that any such materials were removed prior to the execution of this Authorization Form Failure to remove
these Items i*or to cremation may result In harm to the crematory and crematory personnel.
r d litA4 affirm that instructions have been given to Cassidy VonStettina
(fuvrgr D•gcror Nang)
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 Crematorium
( is not re `ible for the removal of personal items from the container or from the remains of the deceased Personal items left In the
container or}i th the remains will be destroyed by the cremation process and cannot be retrieved after cremation
�°� /a hereby authorize Pine View Crematorium
(6.rngwp+g.nU
to cremate the remains of the deceased.
(Initial OPTIONAL)
Uwe hereby authorize the named funeral director to provide for delivery to and cremation by an alternate
crematory,If deemed necessary in the opinion of the funeral director,and to amend this form to provide the correct name and
address of such alternate crematory.
FINAL DISPOSITION
The person authorized to receive the cremated remains of the deceased from the crematory is:
Name-Eileen Odom
Address. 30035 Granda Hills Court,Wesley Chapel, FL 33543- Phone 813-431-5896
The cremated remains of deceased will be disposed of as follows
Mailed through USPS to Eileen Odom 30035 Granda Hills Court,Wesley Chapel, FL 33543
If for any reason the person named above does not take possession of the cremated remains.
Pine View Crematorium is authorized to give possession of
(Cnngray r+rr+1
the remains to Regan Denny Stafford Funeral Home by delivery
(finer)04r4 Fur.-r
in person or by registered mail Thomas Lloyd Mainwaring
DOS-1898-f(Rev 04/20) Page 2 of 3
R
Y
Authorisation for Cremation and Disposition
(indaf the bill-mg)
)
K..,.____�n'1 Cj...1./We understand that if the remains are not claimed within 120 days of cremation,
___._Y- -- _. _._ Pine View Crematorium may dispose of the remains in
an Irretrievable manner,such as by scattering Name nee+rrtryr
CREMATION CONTAINER/URN
(Ite_I l ONE of the following)
n
An urn to be used as a container for the cremated remains has been purchased from RHnm4 Denny Stafford Funeral
and is described as follows.
—.\\\
.1IWe understa`cl that if the urn is too small to hold the entire cremated remains,an additional rigid container may be used for delivery
( OR
K.,..._
m i M Lm is not yet purchased lfWe understand that if no urn is purchased or otherwise provided
---'" _ Pine View Crematorium will place the cremated remains in
(Free of Oomotry)
a ngrd temporary container for delivery
This Authorization Form was provided by Cassidy VonStettina was executed at
(Frw Drat.Nary)
Regan Denny Stafford Funeral Home
(F.,Ham,Noma)
53 Quaker Road,Queensbury,NY 12804
(Erie,Moor Antes)
and is signed by the funeral director as witness to its execution.
I/We have received a completed copy of this Authorization Form.
The person(s)identified below isfare 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 A Form�andaor tzlp(s)the foregoing. L
Signed this 21 st cloy of December i E I l I L CI 1 `"^ l'`,i Ti��'r
Eileen Odom eit.?hi n ,J
rya.d a Printed Mow
30035 Granda Hills Court,Wesley Chapel 33543-
Add n
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TyyedaF+n411pyr,. '------ yQ, o —_. ._
A9D.ss
WITNESS:
Cassidy VonStettina
rywnd Ocecfy re ,r
Typed P, rd Name) (fce'a'f+ecM1r Sy ieur.i —_—.....-
13709
Thomas Lloyd Mainwaring
(Name of Doc.a.dt--
DOS-1898-f(Rev 04/20i Page 3 of 3