Scott, Richard Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: A(Z�t OIJ RETURN TIME:
DOTE & TIME REMAINS ARRIVED AT CREMATORY: z Ig I ZI /I:I c t1r1
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
111A17b( 12Aer5
NAME: IZICNArRD scar' CASE # __--/'s I-_____
TNI PE OF CONTAINER: M�Ilu�s- l�til�ba�.0 �^+6� firet1r
PLACE OF DEATH: 6tMt fills i-Iosei -s'(
ESTIMATED WEIGHT OF REMAINS & CONTAINER 11 ,s /770 6s
PLACED IN HOLD: CI 3S4+1
PLACED IN REFRIGERATION:
DATE OF CREMATION: ZIIOI l(
TIME STARTED: IO-','S TIME COMPLETED: /2:40 f 17
PLACED IN RETORT: ID 10 AllMOVED: IF, 3o / /2 3CM
!WORT # IN WHICH REMAINS WERE CREMATED: 9buf- -
DiTAILED 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.
Nave Yank 9kte
NEW YORK Dep F:4f4t ofMei:te
STATE Division of • t�msl�NOFCEMeTBtISY
OPPORTUNITY_
Cemeteries °wasengto commerce nue
9s ne er ez
Albany.NY 12231-0001
Tetephon°;(S10)47+6226
www.dos.ny.aov
Authorization forCremation and Disposition
This Aulhorlreion Form must be completed and signed prior to delivery of remains for emanation,
nation,
Datee 2[i I 1,1 Number: /cl —
Crematory Name:Pine View Crematorium
Address:Quaker Rd,Oyeenabury,NY 12804
Phone: S(� N S I)))
µ
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation is carried out by placing the remains of the deceased and the ooniabler holding The remains Into a cremation chamber where
they are subjected to intense heat and flame. The heat and items will incinerate and consume everything except bone and metal,
Which ere all that will be Feet after cremation,
Following cremation,the crematory WV lake reasonable efforts to remove all of the•remelns and other materiel from the cremation
chamber,but some minimal duel end residue volt iikelybe left behind..The crematorywill separate incidental encl.forelgn'motertat 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 emel pitcos and placed Isle a designated miner or urn. Cremated remains generally are pulverd:ed until no
tingle fragment is recognizable as skeletal tissue.
OPE°8N__OF THe CONTAINER
The crematory may only open The container holding the un-aamated human remains m limited dreumstanoes,such as to confirm the
Identity of the deceased ar to ensure tryµ no material to enclosed which might injure employees or damage the crematory property_ if
human remains are delivered hr a container which it not suitable for cremation Buell as ceremonlel or rental casket,the
crematofy Will require that the rentable be moved Into a suitable container before It accepts the remains.The opening of e
container or the transferor removal of remains wIN be.00nducked before a witness and will be done in pdvery,with dignity end respect.
£3 N11 ATioN Or ftECEA Eo
None of Deceased:Richard Scott Marital Status:widowed
The Pines,170 Warren Street,Glens Felts.NY 12801
Last Known Address: _
Place of Death:Glen$Falls Hoseitei.100 rk St.,Glens Falls,New York 12801
Sax: ®M 0 r: Age;?Q cola M tjl tli 1.Date of MehlD2106/2021 .Eatlmated Weight \1 ci f.
Description of caekWOontainer In which remains will be delivered.
Matthews Cremation Case Cardboard with plywood
PEftaoR Itt Minn-OF DISPOSITION
(Person(s)In control or ctISposttfod,lattigl ONE of the followig)
I ern/We are the designated agent of the deceased designated.In s wit rewritten instrument executad pursuant to P.ubtic
Health Lew Section 4201.
Tv‘\‘-OR- r
a have no knowledge that the deceased executed a n instrument pursuant to Public Health Law Section 4201 or a
containing directions for the disposition of his or her remains an re are the persons)having priority under Public Health Law
Section 4201 and have the right to authorize cremation of the remains of the deceased. My/Our relationship to the deceased is as
follows: 5 c stew
Richard Scott
DOS-1898-f(Rev.04/20) Page 1 of 3
Authorization for Cremation and Disposition
(Insert Item the list below)
Number s Description:Sister
1. A person designated in writing pursuant to Public Health Lew Section 4201(a):
2. The surviving spouse:
24. The surviving doniestic partner,
3. Any surviving child eighteen years of age or older;
4. Asurviving parent;
S. A suMeing abehg eighteen years of age o•alder,
6. A lawfully appointed guardian;
7. Any parson(s)eighteen years of age or older entitled to share•n the estate and who Ware closest in relationship lo the deceased;
fL A duly appointed IldusteryoftAeestate;
9. A dose blend.or relative wholes execrated a written statement pursuant to Public Health Law Section 4201(7);
10. A deaf flseo dicer of a county or a public admWatrator appointed pursuant to the Surrogate Court Procedure Act
11ta. Any other person Who Is acting on behalf of the deceased and who has executed a written statement pursuant to Public Health
Law Sedlon 4201(7).
aide ALL alb*AllowhIg)
e hereby affirm that the body of the deceased does not contain a battery,battery pack,power Cal.radioactive implant,
or radioactive device end that any such materials were removed prior to the execution dells Authorization Form. Failure to remeaie
these Items prior toeremedon may•resuit in harm tarthe crematory end crematory personnel.
O� e affirm that Instruclions have been given re'Visa K.Parish
cagerd>ng the removal of any person property or otter thing of Wilde which any person signing below or any family member of the
deceased wishes to preserve. Pine View Crematorium
is not responsible ter the removal of personal items from the container or horn theme remains of the deceased. Personal items left to the
container or with the remains will be.deafroyad by the cremation process and cannotbvranieved afteecrematon.
Artie hereby authorize Pine View Crematorium
rcrsY1
to cremate the remabra of the deceased.
Mira OPTIONAL)
thee hereby authorize the named funeral director to provide for delivery to and cremation by en alternate
crematory,If deemed necessary In the opinion of the funeral director,and to amend this farm to provide the correct name and
address of such alternate crematory.
FINAL OltiPO8tTIOt(
The person authorized to receive the cremated remains of the deceased from the crematory la
Name;Carleton Funeral Home,Inc.
Address:68 Main St.,Hudson Fails,New York 12839 Phone:5187474213
The cremated remains of deceased wig be disposed of as follows=
ftetumed to family
if for any reason the person named above does not take possession of the cremated remains,
Pine View Crematorium is artihotiZ+ed to give Possession of
the remains to Carleton Funeral Home,Inc. by delivery
thawal Ham hlrW
in moon or by registered neat Richard Scott
Am;of emend)
003.18SM(Rev.04lwu) Page 2 of 3
Authorization for Cremation and Disposition
(Iota the fellowMa) 'TVA K
e understand that if the remains are not claimed within 120'days of cremation,
Pine View Crematorium
Marra a/ ) -_ may dispose of the remains In
Cnontahv
all Irretrievable manner,such as by scattering.
CREMATION CONTAINER/URN
amp(ONE of the following)
An urn to be used as a container for the cremated remains hos been purchased from
and Is descllbed as follows:
1/We understand that if the urn Is too small to hold the entire cremated remains,an additional rigid container may be used for delivery.
An urn IS hot yet purchgsebWe understand that If no um Is purchased or otherwise provided
Pine View Crematorium
will place the cremated remains'in
ra....c,.„.00,1
a rigid temporary container for delivery,
Tide Authorization Form wee provided by Mark K.Parish was executed at
(neaarCNsavName)
Carleton Funeral Home.Inc.
"Mal Memo Maw,
68 Main St..Hudson Falls,New York 12536
Forewormai Addeo)
and is signed by the funeral director as witness to Its execution.
Me have received a completed copy of this Authorfzatlen Form,
The pereon(s)identified below Iafare the persons)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 eutherize(a)the foregoing.
Signed this 6 _ day of February ,2D 21
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ravo aroma,,cad
Richard Scott
jm a ors Oar o
Do9.18811-f(Rev.04120) Page 3 of 3