Bundrick, Damien Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: 6Fk C. RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: /1111?1 / 40�1
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
hIC .40-L MU
NAME: PArrao 1300DRyc CASE #
TYPE OF CONTAINER: ht. 00,11 ¢151( `u iiu( -a0' ({,i(oftee
PLACE OF DEATH: IS.)3 Will 1,I1I1 Ro,ci F1td!(c )1g3r
ESTIMATED WEIGHT OF REMAINS & CONTAINER -'i tic / Z?c lir
PLACED IN HOLD: 2 P
PLACED IN REFRIGERATION:
DATE OF CREMATION: 1 )10 )Z 1
TIME STARTED: R' 1 IJ TIME COMPLETED: 2 zcf R
PLACED IN RETORT: iZ'-tq n MOVED: I ''f 1 r 2 Qom
f
RETORT# IN WHICH REMAINS WERE CREMATED: S4I rFK k
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE:THE CREMATION LOG SHALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
New York State
Department of State
NEW YORK Division of DIVISION OF CEMETERIES
STATE OF One Commerce Plaza
OPPORTUNITY_ Cemeteries Al 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.
January 16,2021 f/
Date: _ Number: _ _' l�le
Crematory Name: Pine View Crematory
Quaker Rd,Queensbury, NY 12804 518-745-4477
Address: Phone.
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 win 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 respell_
IDENTIFICATION OF DECEASED
Damien Bundrickl ISM' Married
Name of Deceased: Marital Status:
1573 Hadley Hill Rd., Hadley, NY 12835
Last Known Address:
residence
Piece of-Death:
1/16/2021 245
SOX: M F Age:66 DOB: 2/3/1954 Date of Death: Estimated Weight:
Denton of casket/container in which remains will be delivered.
M - aid basic cremation container, no interior; wood reinforced
� L OF QISPOSmOP(
trrl of disposition,iftiel ONE of the following)
irx-I: eiarethe ted agent of the deceased designated in a will or written-instrument�t
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Authorization for Cremation and Disposition
(Insert from the list below) spouse
Number. Description:
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 persons)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 Surrogates 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).
(In'"al ALL THREE of the following)
o� „• 1/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 arty 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.
Patricia Miller
F Uwe affirm that instructions have been given to
(Funeral Director Name)
regarding the removal of any
tory
personal property or other thing of value which any person signing below or any family member of the
Pine View Crema
deceased wishes to preserve.
(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.
Pine View Crematory
&e
WYe hereby authorize at
(Crematory Name)
to cremate the remains of the deceased.
(Initial OPTIONAL)
Urre 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
addren::of r, crematory.
ed-tb receive the cremated remains of the deceased from the crematory is:
t
.r ..
51 _ 1v 4ra4Fa #ome,Inc. PhoneNare °iL Luzeme,NY12346
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~ Authorization for Cremation and Disposition '.
(Initial the following)
I/We understand that if the remains are not claimed within 120 days of cremation,
�f+'ini'View Crematory
may dispose of the remains in
(Name of Crematory)
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
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-
„b3eiit_.An urn is not yet purchased. lNVe understand that if no urn is purchased or otherwise provided
Pine View Crematory will place the cremated remains in
(Name of Crematory)
a rigid temporary container for delivery.
Patricia Miller „ executed at
This Authorization Form was provided by
(Funeral Director Name)
Brewer Funeral Home.Inc.
(Funeral Home Name)
24 Church St.,Lake Luzeme, NY 12846
(Funeral Home Address)
and is signed by the funeral director as witness to its execution.
I/We have received a completed copy of this Authorization Form.
The persons)identified below is/are the person(s)in control of disposition,who by signing this Authorization Form,attests)
to the accuracy and completeness of the information contained in this Authorization Form and authorizes)the foregoing.
16 January 21
Signed this day of ,20
Joy R.Brooks-Bundrick �;�',�J(� - C j«LZ.i�G
Typpq prPrirHed Name Sign2 V
1573 Hadley Hill Rd., Hadley, NY 12835
Address
Typed or Printed Name Signature
Address
Typed or P4kiad Name Signature
Address
MM TtESS:
Plittie Miller nn
a a ;
Typed aPr®MsdName) (Funeral Meador �:
Wiilitswenttursibo
Damien-Bundridcrt
,T h ta4 f ,Y.
DOS-1898-f(Rev.04/20) .