Malone, K. Teresa Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: 33 d-]v.J- /C /�-P1'ma7T RETURN TIME: /✓4/
DATE & TIME REMAINS ARRIVED AT CREMATORY: //4-- " 2- , e)-Za Z/
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
3 ; /V file f
NAME: A e 5 a , ?a lo.J P CASE #
TYPE OF CONTAINER: -'or-e.,..)co Ce 5 k{7 ec,41,,tv/`t.t ,A;c,J Cav,4,.,.,cr/( JJvcr,4-rL tfo,,,-J
PLACE OF DEATH: t 5/e ti41_ &c �°!J-W - 15/ 2 ✓�✓C.e 1'.
So % I6
,r fir-, ��, �/ / 8 // /
ESTIMATED WEIGHT OF REMAINS & CONTAINER PP-- /,65 Pi /4h SG,c,J41
PLACED IN HOLD:
PLACED IN REFRIGERATION: //
DATE OF CREMATION: a- alb -- az /
TIME STARTED: jY1.-- TIME COMPLETED: 2 5 Cfn
PLACED IN RETORT: /? MOVED: /-
RETORT# IN WHICH REMAINS WERE CREMATED: f ekt.,yvF p� k t
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
t of DNISION OF CEMETERIES
^ � Division STATE OF One commerce Plaza
Cemeteriese
OPPORTUNITY_ A 99 Washington Albany,NY 122 AvenuAvenu 1
Telephone:(518)474-6226
www.dos.ny.9ov
Authorization for Cremation and Disposition
This Authorization Form must be completed end signed prior to deliveryof remains for cremation.
i �
FEBRUARY 19,2021 Number. 2021-012 t
Date:
Crematory Name:PINE VIEW CREMATORIUM
Address:QUAKER ROAD QUEENSBURY,NY 12804 Phone: 518-745-4477
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
emae is carried intenseIacing the remains of heatt and flame. Thethe deceased and heat and flame will Ine cinerner ate andtng the remains into a co consume everything except bone and metal,
they are subjected to
which are all that will be left after cremation.
Following cremation,
t somenm nieimal dust and will
residue will likely be left behind. The le efforts to remove all
will remains
separate incidental nd foreign cremation
mater al from
t chamber,
the remains thin incidental
and placed into a designated container or urn. Cremated remains generally are tns will be pulverized until no mechanically
pulverized into smallpieces
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
for cremation such as ceremonial or rental
human remains will fequiredeliveredth e in
be moved into a suitablontainer which is not e container before t accepts the remains. The opening of a
crematory g
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 NEVER MARRIED
Name of Deceased:
Marital K TERESA MALONE l Status:
131 LAWRENCE ST SARATOGA SPRINGS,NY 12866
Last Known Address:
WESLEY HEALTH CARE CENTER,INC.131 LAWRENCE ST SARATOGA SPRINGS,NY 12866
Piave of Death:
Sex: D to I F Age:97 DOB:
08I30/1 823 Date of Death:02/19/2021 Estimated weight: 45
Description of casketicontainer in which remains will be delivered.
FLORENCE CASKET COMPANY/CREMATION CONTAINER/ CARBOARD/FIBERBOARD
PERSON IN CONTROL OF DISPOSITION
(Person(s)in control of disposition, initial ONE of the following)
1 amlWe are the designated agent of the deceased designated in a will or written instrument executed pursuant to Public
Health Law Section 4201.
OR-
``,• - L'We have no knowledge that the deceased executed a written instrument pursuant to Public Health Law
aw a Neonh 24201 or a
wilt containing directions for the disposition of his or her remains and liwe are the person(s)having P ty under
Y\
Section 4201 and have the right to authorize cremation of the remains of the deceased. MyiOur relationship to the deceased is as
follows: K. TERESA MALONE
Wanri of Deceased)
Page 1 of 3
DOS-1898-f(Ray.04120)
Authorization for Cremation and Disposition
(Insert from the list below)
Number: 7 Description: Eirr- CarJ.C/1-7 '
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 snare in the estate and who isiare closest in relationship to the deceased;
b. 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 wino 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)
battery pack,power cell,radioactive implant,
ifWe hereby affirm that the body of the deceased does not contain a battery,
or radioactive device and that any such materials were removed prior to the execution of this Authorization Fonir aiiure to remove
these items prior to cremation may result in harm to the crematory and crematory personnel.
•
lfvVe affirm that instructions have been given to
JAMES P.McDERMOTT
(Funeral Margot Name)
regarding the removal of any personal property or other thing of value which any person signing below or any family member of the
PINE VIEW CREMATORIUM
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.
f PINE VIEW CREMATORIUM
ilWe hereby authorize (catnaroa )
to cremate the remains of the deceased.
(Initial OPTIONAL)
1/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:
JAMES P. MCDERMOTT OR EMPLOYEE
Address: 9 PINE ST.CHESTERTOWN,NY 12817 Phone:
5184942811
The cremated remains of deceased will be disposed of as follows:
IN R IN-ST.CECILIAS CATHOLIC CEMMIETEI Y WAiRiziEUSEURGAW
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
Ic ma ory Namq
BARTON-McDERNIOTT FUNERAL HOME,INC. by delivery
the remains to (Funeral Noma Nano)
in person or by registered mail. K TERESA MALONk
(Name o(Deceased)
er r~tf Cl i r e etO Page 2 of 3
ihi `. tr
DOS-1 ti98 f(Rev.04/20)
l'>C3 C. ( ct k+:r {1 u S been1 'rr(c V r .
Authorization for Cremation and Disposition
(initial the following)
ifv le understand that if the remains are not claimed within 120 days of cremation,
PINE VIEW CREMATORIUM may dispose of the remains in
(Name of Crematoty.i
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:
lNVe understand that if the urn is too small to hold the entire cremated remains,an additional rigid container may be used for delivery.
CR
. f'• An urn is not yet purchased. INVe understand that if no urn is purchased or otherwise provided
PINE VIEW CREMATORIUM will place the cremated remains in
(Names of Crernaiory)
a rigid temporary container for delivery.
JAMES P.MCDERMOTT was executed at
This Authorization Form was provided by (Funeral Q.reaor Name)
BARTON-MCDERMOTT FUNERAL HOME,)NC,
(Funeral Home Name)
9 PINE ST.CHESTERTOWN,NY 12817
(Furarat Horne Actoess)
and is signed by the funeral director as witness to its execution.
IiWe have received a completed copy of this Authorization Form.
The person(s)identified below isiare 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 Authorization Form and authorize(s)the foregoing.
10TH dayof FEBRUARY ,20 21 , a JUDYItti rv1ARTINEZ
Signed thiso ti� a St u'Flonca
t 1 FT; i' l ` (!L. iEt to yr ,c 1� ' n;♦�( � {Corn, u 'G� ' - -
omit,�j nt1t� F.5}r 1e E,_
iy�adafPnnleONance L Y is L .3 5 q- r,^"
13 J 4 'E.: 1 L! 1,�'i t 4e t'_. ('_( / }'�t I1 C 1'-S::i,"i� J ..._,�,...
ma.
ypt,a- rip1,,a Nance 5ivatute
Ackifess
fy,xid or Piloted Nitinti Signature
Address �+
Yd1TNESS:
JAMES P.McCERMOTT .91 '
(Furwrai on�ectar 7ypW w Printed Name)
12330
iRegrskotien 7+w !)
K.TERESA MALONE
(Hama of&mused)
Page 3of3
DOS-1898-f(Rev.04120)