Russell, Robert Paul I
Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
1
F i ERAL HOME: �eilt,J, Der'4/ 5 4(j RETURN TIME:
D '!TE & TIME REMAINS ARRIVED AT CREMATORY: iv -- A-6-tea
N '`ME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
*I ' Des, Mt, -
N ME: l�pt'J J-4 IK 55R.l/
"� / II CASE # 1LJ,1
T .'PE OF CONTAINER: is ad 4, el
)- -- 4 J 1e CAlc e i
Ccn ...-
P 'CE OF DEATH: /5 Brri,l7 Letr)C, 60140(3 Lao; i,, , / /249/4/
E'TIMATED WEIGHT OF REMAINS & CONTAINER I /1e a3A5 SC.t,I,.e..
P ' CED IN HOLD: 74---
P 'CED IN REFRIGERATION:
D TE OF CREMATION: o2-6 -�0-2,
TI E STARTED: r% Z TIME COMPLETED: I it
P ' CED IN RETORT: /O*jam— MOVED: i/ Zrr,,,.-,
R• TORT # IN WHICH REMAINS WERE CREMATED: $yes eo 5 f k.
D• TAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
F'OM TIME OF ACCEPTED DELIVERY:
N'i TE: THE CREMATION LOG SHALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
02/05/2021 1 El:49 5403614977 PAGE 10
New York State
<is,EW YORK Division of `3 Department� a�
TATE OF , DIVISION OP CEMETERIES
PPOItTUIVI OPPORTUNITY. 3
/'�Cemeteries} One Commerce Plaza
�.rs s*Q6 ��.*! 99 Washington Avenue
Albany,NY 12231-0001
Telephone:(518)4748226
www.dos.ny.yov
Authorization for Cremation and Disposition
This Ar ptprijsHon Form must be completed and signed prior to delivery of remains for cremation.
Date: 02/04/2021 V IC
- Number: -
Crematory Name:Pine View Crematory
Address:Quaker Road.Queensbury,NY 12804 Phone: (518)745-4476
•
CREMATION IS AN IRREVRRSIOL,E AND FINAL PROCESS.
Cremation is carded 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 end tieing. The heat and flame wIN 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 lett behind. The crematory will separate Incidental and foreign material from
the remains and the incidental end 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. Crenated remains generally are pulverized until no
single fragment is recognizable as skeletal tissue.
IIthG THE CONTAIN
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 a tsure 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 will 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 respect
JDENTIFICATION OF DECEASECI
Name of Deceased: Robert Paul Russell Maio ice. Divorced
Last Known Address:l5 Braley Lane, Belton landing, NY 12814
Place of Death:, 15 Braley Lane, Bolton Landing, NY 12814
Sex: ®M 0 F Age: 43 DOB: 03/19/1977 Dalo of Death: 01/23/2021 Estimated Weight: ,9 412
Description of casket/container In which remains will be delivered. •
Alt Container—Buffalo Casket Company
PERSONJN CONTROL OF DISPOSITION
(Pe►son(s)in control of disposition,initial ONE of the Mowing)
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-
GPS UWe have no knowledge that the deceased executed a written instrument pursuant to Public Health Law Section 4201 or a
will containing directions for the disposition of his or her remains and I/we are the persons)having priority under Public Health Law
Section 4201 and have the right to authorize cremation of the remains of the deceased. MylOur relationship to the deceased is as
follows:
•
Robert Paul Russell
None of Damn*
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Authorization for Cremation and Disposition
(Insert from the list below)
Number 3 Desrxiption:Child over the axle of 18
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 Israre closest in relationship to the deceased;
8. A duly appointed fiduciary of the estate;
9. A close friend or relatrlre 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).
Mg ALL THREE of the following)
0' itWe hereby affirm that the body of the deceased does not contain a battery,battery 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
these Items prior to cremation may result In harm to the crematory and crematory personnel.
69$ 1/We affirm that instructions have been given to Mark J. DeSimone
Funentairecia,r
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
(Pavan,None)
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.
1 uwe hereby authorize Pine View Crematory
Aswan,NonW
to cremate the remains of the deceased.
(tn OP77ONfAL)
Ave hereby autborfze the named funeral director to provide for delivery to and cremation by an alternate
crematory.If deemed necessary ih the opinion of the funeral director,and to amend this form to provide the coned name and
address of such alternate crematory.
FINAL DISPOSITION
me person authorized to receive the cremated remains of the deeesaed from the crematory Is:
Name-Regan Denny Stafford Funeral Home, Mark J. DeSimone
Adder: 53 Quaker Road,Queensbury, NY 12804 Phone- 5518)792-1114
The cremated remains of deceased will be disposed of as follows:
Return to family
If for any reason Meyerson named above does not take possession of the cremated remains,
Pine View Crematory is authorized to give possession of
X+ n+ -
the remains to_ Regan Denny Stafford Funeral Home by delivery
rramsi
In person or by registered mail. Robert Paul Russell
(rem.a c.auuv5
DOS-1898-f(Rev.04/20) Page 2 of 3
02/05/2021 18:49 5403614977 PAGE 12
Authorization for Cremation and Disposition
Mat the following)
( 1 $ IlWe understand that if the remains are not claimed within 120 days of cremation,
Pine View Crematory may dispose of the remains in
.erci.r.aM
an irretrievable manner,such as by scattering.
CREMATION CONTAINER/URN
Wig ONE of the(blowing)
Regan Denny Stafford Funeral
An urn to be used as a container for the cremated remains has been purchased from M„„„d
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-
ri An urn is not yet purchased. I/We understand that If no urn is purchased or otherwise provided
Pine View Crematory will place the cremated remains in
•
(Myna ar
a rigid temporary container for delivery.
This Authorization Form was provided by Marls J. DeSim0ne was executed at
Ir unsill A9wbr Wore)
Regan Denny Stafford Funeral Homerunatal _
mi
53 Quaker Road,Qu ensbury, NY 12804
fuming Mune Adaew)
and is signed by the tunemi director as witness to its execution.
I/We have received a completed copy of this Aufhortzeflon Form.
The person(s)identified below Ware the poisons)In control of disposition,who by signing this Authorization Form attest(a)
to the accuracy and completeness of the information contained in this Authorization Form and authorizes)the foregoing.
signed thla 4th day of February .20 21
•
Collin Smith
Typed&RigsdNemo
Sot Fox Grose
7ypedaf+rkdedNrnre to/ri "i t�
City/County of C p d
Addles.
This meta� ,�e.^acknowiiedged b re
TypedarRinkiMame ,on, Y of lJ
Aaais.e JANAt A-1'-Pt''R'Cft:4"
NOTARY PLIC
WETNESS: Itc's Signature REGISTRAT ON*B 3921336
COMMONWEALTI4 OF VIRGINIA
Mark J. DeSimone MY COMMISSION EXPIRES
(F..yferfic cww Two er%wed NMmrJ Dkeuror
10919
Robert Paul Russell
yaw atOeee..ed - --
DOS-18084(Rev.0420) Page 3 of 3