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Prentice, John T.
Pine View Cemetery & Crematorium Quaker Road Queensbury, NY 12804 (518) 745-4477 or (518) 745-4476 FUNERAL HOME: hg tei.c wig RETURN TIME: DATE & TIME REMAINS ARRIVED AT CREMATORY: ii ZO J t I0 �51 NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS: NAME: JO�N /J iTCE CASE # 7Z TYPE OF CONTAINER: a ma Of /4-16 PLACE OF DEATH: tlfl3 54x.te rot.Ale 'W , PI* 1 t Pal i ESTIMATED WEIGHT OF REMAINS & CONTAINER Too ay. I/341T PLACED IN HOLD: �!goo At/ PLACED IN REFRIGERATION: DATE OF CREMATION: i lZ� IZt q TIME STARTED: I t6 0 TIME COMPLETED: Z:561 Y., PLACED IN RETORT: i1 MOVED: 2: c`'I RETORT# IN WHICH REMAINS WERE CREMATED: (10 PA VTF 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. 01/19/2021 21:40 5187477548 MBKILMER PAGE 01 •wN,rV.J_,U iur—J.D t'Nl?t 6'2 bJl New York State Department of State NEW YORK Division of DIVISION OF CEMETERIIS STATE OF Ono Commerce PIsta ORTUNft''r. Cemeteries 99 WashIngror Aram. Aluany,NY 12231-00ot Telephone,(51Bi 474-6276 www.downy gov Authorization for Cremation and Disposition Thin Authorikatfon Penn must be completed and signed prior to delivery of remains for cremation. January 9,2021 Date' ----- — —_�— Number ---.._..� .2__ _. Crematory Name: pine yew Crematory 21 Address. Quaker Road, Qwsnebury, NY 12004 TMV`r --- ^+ Phone 518.745.4477 -- -____... CREMATION 16 AN IRREVERBtELE_AND FINAL PROCESS. Cremation is carried out by placing the remelne of the deceased and the container haling the rer rains;into a cremation cnarrter when they ace sue ec1ed to intense heet and Name The heat and flame will Incinerate end ooneume everything except bone and metal,j ,which small that will be left after cremation, 'Fouowing tremeNAr, the orernstory will tete teeconeble efforts to'armee all of the remains rued other material from tt cremation i chamber,but some minimal dust end residue will likely be el•Ashmd The crematory will separate incidental end foreign Material from the terrains and the incidental and foreign meter)®I wit be disposed of as required oy law. The cremated remains wi!I be mechanical y ptilvtrited Into smell oiecee and oiaced into a dcniprated ronrainer Or err Cremated remains generally ere pulverized until re *Ingle fragment Is recognisable as skehtai tissue, OON{f TH colt The crematory nay only open the container holding tMe um cremated human renrsina in limited circumstances.s.icir as to confirm the dentity of the deceased or to ensure that nc material Is enclosed which might Injure employees or oamag•the crematory property. It human remains ere delivered In a container which is not suitable for cremation such as oarimonial or rental ryeket,the crematory will require that the remains bs moved into a suitable container before it accepts the remains. The opening of a r:/ntsine-or the transfer or removal of remains wilt be co'd;Jctsc before a witness end will be done in privacy.with dignity and respect. WENTIFICAt'tQN OP DECEASED John T.Prentice Never Married Name at CeatseC Marital Status.4573 State Rt.40,Argyle. NY 121809 Last Known Address .._. 457,3 State Mt.40,Argyle.NY 12809(Washington Center) Plgce of Death' Sex ®M ©F Age'90 cog 03/061/93q data of vein 01/OAI2Q21 Estimated Weight 200 plow:npll n of oeeitet/oontairn•r it wnibh remains will be a livered Minimum Cremation Casket, Fiorenoe Casket Co. Cardboard'Pine -- PERK IN IN CONTROL Of Di$PQJ jgy (Person(s)In control of disposition lime!ONE of the Wowing) -..,._.,_...,,_ i areMM are the denigrated agent of the deceased designated In a wilt cr written rIstrurntrit syecutsd pursuant tc Pub!ic Health Law Section 4201 -OR_ 1 �� INVe have no knowledge that tre deceasede,eArx,ter;a written Instrument pursuant to Puht�c Health Law Section 42C1 or a II!containing directions for the dlepoettlon of his or her renelrs ant IAA,are tee personls;having prinriry under Public,Health low Section 4201 and have the right io aut'turite:remotion of the terrains of trio deceased. MylOur relationship to the deceased la as follows. - S eel:%1d C4;i,010 John T. Prentice ._,_� -.....� mimeo,o,Orannel ODS-1b95-f(Rev.04201 Pegs 1 or 3 61/19/2021__ 21:40 5187477548 MBKILMER PAGE 02 Authorization for Cremation and Disposition (Insert from the lief beroW1 Ptumt?ei.._` Descrioion. Any pit man t$veersof ego o older entitled to share in the estate and who Is closest in relationship 1. Apr raon designated In writing pursuant to Public health Law Section 420"(3); 2. The surviving spouse: 2a. The surviving domestic partner; 3. Any surviving child eighteen years of eqe or older. 4. A surviving parent; S. A sun/Nine sibling eighteen years of age or older; 6. A lawfully appointed guardian', T Any pereon(s)eighteen years of age or older entitled to share In the estate and whet Itsare closest in relationship to the deceased; 8. A duty appointed fiduciary o1 the estate. Si. A close time or relative who has executed a written statement pursuant to Public Health Law Section 4201(7), 10, A chief fiscal officer of a county ore public sdministretor appointed pursuant to the Surrogate's Court Procedure Act, 10e. Any other person who is scbng or behalf of the deceased end who has executed a written statement pursuant to Public Heath Lew Section 42V1(7) (JrtlfNAf ALL THREE of the fblfowlog) IMM hereby effirm that the body of the deceased cons not nontein a battery,battery pack,power cell, radloactve implant, or radiooctve device and that any such materiels were removed pr,or to the execution of this Authortration Form, Failure to remove thee*Items prior to cremation may result in harm to the crematory end crematory personnel. INVe affirm that Instructions have been given to Stephente A.Oilman "emiranor+va..er regarding the removal of any persons!property or other thing of vett a wh►cr any person signing below or any hiniry.member of the deceased wishes to preserve. Pine�Vier Crematory tentiiolery Nens) in not responsible for the removal of personal Items from the container or from the remains or the deceased Personal Items left In the container or with The ram&ns will be destroyed by the cremation proceee and cannot be retrieved after cremation I Pone View Crematoryroviiarey Wine — - — --- —— -— Hwy Hereby authorise to cremate the reelable of the deceased. (!Ri OPPONAL) _-- Uwe hereby authorise the named funeral director Io provide for delivery to and cremation by an alternate r.rematory.If deemed necessary In the opinion of the funeral director,and to amend this form to provide the correct name and address of such eltemete crematory. fNALtZP DO$JTJDy e person authorized to receive the cremated remains of the deceased from the crematory is. M.a Kilmer Funeral Horne Address 82 Broadway.Fon Edward,NY :2a28 Phone. 518-747.826B The cremated remains cf daceewd will be disposed of as follows It for arty reason the person named above does not take possession of the creroated remains, Pine View Crematory -_ - is authorized to give possession of (COmwary None) the► rrooins to M BKilmer Funeral horns -� -_-__ by delivery AFune/ninon.Name) n person or by reglota ed mat John T. Prentice --- - (Wrens o�DwwwAOi..• DOS 18id8.t(Rev. 04/20) Pape 2 03 01/19/2021 21:40 5187477548 MBKILMER PAGE 03 Authorization for Cremation and Disposition (tq(the toirnw)rrq) I/We unahratartd that if the remains are not claimed within 12C Jaye of cremation. PirH View Crematory-- -- - - -_-may depose of the refrains:n owe,*of cre/r.eroy, a rst'ieveble manner,such us by scattering CREMATION caMTAINeR/URN (boat ONE of the holtowrng; An urn to be used es a container for the cremated remain&nee been,purchased from ono Id described as lOIICws` _-. - -- ------ -�_ !We jnders[and that If the urn le too small to hold the attire cren eted remains,an PddrtIona: r d 0un1eir0•rnait tie used°or delivery .UA. 1„, -An urn is not yet purchased INve understood that if no urn s purchased or otherwise provided Pine Vew Crematory will place the oremeted remeios in Frpn•orCrr,�lky. e rigid temporary container fc delivery This AuthorizatMn Form was provided by Stephanie A ,31Irrten was executed at rii-W/eMruriv1 r•om.) M,13. Khmer Funeral Horne •___—` (Fc!elr1.H1n1!Owe) 82 Broadway,Fort Edward rnv 12828 --- - kdval.1- - ----. ---- - -- and is Inched by the funeral d recto all witness to Its execu:uon 1/Wei neve received a completed copy of this Authorization Porm. The persona))Identified below Ware the personae; In control of dtspO&&Uon,who by signing this Authorization Form.*testis) to the accuracy and completeness of they lntormat)on contained in tills Aut?orizaVori Form and authorizele)the foroaoing. Signed this 9 day of _ ` .20 21 Chrf9tene Swart . `:, tr ck r-1 .P. . tow^o,rT+roanlly _..-•-------- „ -,_....r-.�.�_...__. 8 Rowland Street,Apt• 2. Marblehead.MA C1945 Matthew C.MANY r,rocJ PM a • i pON0lp04.416 T 1 oP MABS -MUsEr c _.. Corl+Mltelo" Expires WITNS6• Ste:haola A. Gilman (PM*IQ.00 *I Pow Aim-ICa, Y., "awe' ...... 14163 John 1' Prentice Page ofDoss-1898 f(Rev, 0gr20i ;