Isidore, Edward Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: f16 Kstivify RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: L/Z I 71 /0.1oftri
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
lyt kLLM
NAME: 01- TS rk° CASE # 1 Z-3
TYPE OF CONTAINER: f to rc (silt l� nM 74„`iactfv( 'RnL
PLACE OF DEATH: itt ales !`yam
ESTIMATED WEIGHT OF REMAINS & CONTAINER (30 /
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION: 213J Li
TIME STARTED: /rOokti TIME COMPLETED: /I1 DOM
PLACED IN RETORT: /11) '`'F MOVED: �� ��i � J� 'i0
RETORT # IN WHICH REMAINS WERE CREMATED: tZWEIL filWX
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
NEW YORK ��° ° ~ ^�� Depa�n,entnvState
TATE OF ��0��Nm�N���� ��0 DIVISION OFCEMETERIES
OPPORTUNITY. �-��N����f���N°~��N� One Commerce Plaza
Cemeteries N��=w ys Washington Avenue
Albany,wY12z31'0OVl
ro/p»xone:(u1u)*74-*aza
Authorization for Cremation and D^Spos^tion ~,w,uosnvnov
This Authorization Form must be completed and signed prior to delivery of remains for cremation.
Date:U1/31/2O21
�- Number: /7 ��
-- - / ~-�
Crematory Name:Pine View Crematory
Address:Quaker Road, OueonoUury` NY 412804 ----------- -------- -
518'745~4470
-- --- --____' Phone:
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation is carried out by placing the remains of the deceased and the container
' holding - �--"."x ".=s"bvec,°u'v mtenaeheat and n 'flame. The heat and flamoevviU consume - -'-'~/
| which are all that xvi|| be left after cremadn. onmun*mm«m��hingemcep�boneandm��/|.|
� Following cremation, the crematory will take reasonable e#nnyto remove all of the remains and other material from the cremation
� ber, but some minimal dust and residue will likely be left behind. The crematory will separate incidental and foreign material from
thp remains and the/ pulverized incidental� - -- -~'g ' ^'~~''"'will be disposed w *u /vqmxeooy�w. The e�� i -«�
� di ��-� -- '' ~~ ^~~~^^~~'�
'
single fragment recognizable--skeletal -tissue.
OPENING OF THE CONTAINER
The crematory may only open the container holding the un'orematedhumao remains in limited circumstances. ouch uo8oconh the
�emi4'o/mn deceased o,to ensure that numa�ha{ in enclosed which might injure employees or damage the crematory property.
Ifhumanremainaarmde|ivw,edinanontminovxvhichianotsu�mbbmfmrormn�mmionwuchasoermrmunim| or rental casket,the
p�nv�
crematory �require that the remains bewved in�meou�� nn
��w��m�a�mwrbw�mnm i�acco�tmxhe nwai''s. Thooponi
vxwillmn nyv' m
container or the transfer or removal of remains will be conducted before a wi.tness and will be done in privacy, with dignity and respect.
IDENTIFICATION OF DECEASED
Isidore
Name c<Dacemued�� Edward °*doe Married
Marital Status:
Last Known Address:31 Kimberly Lane, Qupenubury, NY 12804
Place of Death:Glens Falls Center. Sherman Avenue, Ouoenobury.NY128U4
Sex: I@ M [IF Age:89 DOB- 05/26/1931 130
_DmusofDeath:�1/31/2U�1 Estimatedyy ev]ht:
Description of casket/container in which remains will bodelivered,
Minimium Cremation C8skGt/DinR/Ca[d board, F|OrBOCe Casket CO.
PERSON IN CONTROL 0FDISPOSITION
(Penaon*;/ncoo/nofnf disposition, initiat ONE of the/bXowing)
-' --' 1 am/We are the designated agent of the deceased designated in a will or written instrument executed pursuant to Public
Health Law Section 4201.
'
� |/Ne have no knowledge that the deceased executed a written instrument pursuant to Public Health Law Section 4201 or
ill con g 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 ofthe remains/f the deceased. My/Our relationship to the deceased is as
follows:
EdVV0Rj isiodOFe
- ----- -��=°v/o��nm-- ----------
U08'11898't (Rev. 04/2O) Page 1o/3
Authorization for Cremation and Disposition
(insert from the list below)
2
Number: _.__. Description: surviving spouse
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)
lANe hereby affirm that the body of the deceased does not contain a battery,battery ry 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
the items prior to cremation may result in harm to the crematory and crematory personnel.
I/We affirm that instructions have been given to Todd G.Kilmer
(Funer)l£ rector 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. %ri/cv'
(Crematory Name)
is not responsible for the removal of personal items from the container or from thremains of the deceased. Personal items left in the
contairIAlle
er or with the remains will be destroyed by the cremation process and cannot be retrieved after cremation.
hereby authorize nAJ
Crematory Name)
to cremate the remains of the deceased.
(Initial OPTIONAL)
i/we 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: M.B.Kilmer Funeral Home
Address: 136 Main St. South Glens Falls, NY 12803 518-745-8116
Phone:
The cremated remains of deceased will be disposed of as follows:
Release to Michael&Christina Quill
If for any reason the person named above does not take possession of the cremated remains,
Pine View Crematory
is authorized to give possession of
(Crematory Name)
the remains to M.B. Kilmer Funeral Home
by delivery
(Funeral Home Name)
in person or by registered mail. Edward Isidore
(Name of Deceased)
DOS-1898-f(Rev. 04/20) Page 2 of 3
e
Authorization for Cremation and Disposition
(l .ial t following)
Ai
.01N I/We understand
a d that if the remains are not claimed within 120 days of cremation,
Pine 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:
I/We understand that if the urn is too small to hold the entire cremated remains, an additional rigid container may be used for delivery.
-OR-
An urn is not yet purchased. l/We 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
This Authorization Form was provided by ___ was executed at
(Funeral Director Name)
(Funeral Home Name)
136 Main St. South Glens Falls, NY 12803
(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 person(s)identified below is/are the person(s)in control of disposition,who by signing this Authorization Form,attest(s)
to the accuracy and completene�sss of the information contained in this Authorization Form and authorize(s)the foregoing.
Signed his �i/ day of I--eK1rl( r , 20 j
�rCc���r(p� i�✓t�S
I_isa D+etafia P A For Anne Isidore
Gel
Typed or Pn'nted Name —____ .-. __-._
92 Remsen Road,Yonkers. NY 10710
Typed or Printed Name Signature
— —
/�ed w Printed Narra�'------__.__.v_. ..--------- Signature ._._._...._.--.— -----
Ta
Address _ ._ ...._ __- _..._._—�._
WITNESS: n' * )3 +Todd G. Kilmer
(Funerar Director T or Printed Name) -----
YPt+d —__.._ (Funeral Director Signature
)
11879
(P'egratralkxr Number) ��-
A
Edward Ispdore
(Name of Deceased)
DOS-1898-f (Rev. 04/20) Page 3 of 3