Baltina, Mala Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: S_ S .12 RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: 2/II J 21 I). 10
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
FRS;Lodi Vod si-V1 LW\
NAME: MA-7-Pt 3P t TI IAA CASE #
TYPE OF CONTAINER: I1<(�I�,,r _ (�'Q.,n� c,ba„ 6,0.4
I
PLACE OF DEATH: 4n3 5-kie KdLlte Ar)/ IU01
ESTIMATED WEIGHT OF REMAINS & CONTAINER /1 S I.�r / //k
PLACED IN HOLD: '1•5J
PLACED IN REFRIGERATION:
DATE OF CREMATION: d"/3- .20,.Z./
TIME STARTED: 7'-k--' TIME COMPLETED:
fl� 9 5,3
PLACED IN RETORT: 7 MOVED: 3
RETORT # IN WHICH REMAINS WERE CREMATED: etx,;e,-- P
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.
02109/2021 12:06 (FAR)5187616499 P.002/013
New York State
Pepertment of State
IdEWYORK Division of DIVISION OF CEMETERIES
STATE OF One Commerce Maze
4 OOPPORTuNITv. Cemeteries 99 Washington Avenue
Nbeny.NY 12281-0001
Telephone(6A47448228
W W Wdoe.ny,gvv
Authorization for Cremation and Disposition
This Authorltatlon Form must be completed and eigned,prtor to delivery of remains for cremation.
Date:02/09/2021 Number: l 19
Crematory Name:Pine View Crematorium
Address:51 Quaker Road,Queensbury,NY 12804 Phone: S5181745-4477
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation is carried 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 and flame. The heat and flame will incinerate and consume everything except bone and metal,
which are all that will be left after cremation.
Following crematlan,the crematory will take reasonable efforts to remove all of the remains end other material from the cremation .
chamber,but some minimal dust and residue will likely be left behind. The crematory will separate incidental and foreign materiel 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 small pieces and placed Into a designated container or urn. Cremated remains generally are pulverized until no
single fragment is recognizable as skeletal tissue.
OPENING OF THE CONTAINER
The crematory may only open the container holding the tin-cremated humeri 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
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 wi l be done in privacy,with dignity and respect.
JDE NTIFiCATION OF DECEASED
Name of Deceased:Main Saltine Marital Status: Widowed
Last Known Address:4573 State Route 40,Argyle,NY 12809
place of Death:Washington Center,4573 State Route 40,Argyle,NY 12809
Sex IJ M tg1 F Age: 95 b0e: 05/04/1925 Date of Death: 02/08/2021 Estimated Weight: ) I 5--
Description of casket/container In which remains will be delivered.
Fiberboard/alternative container,Matthews Company
PERSON IN CONTROL OF DISPOSITION . . '
(Person(s)in control of disposition,/p/tlal 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.
-Q
•
•.�'�i AI Wife have no knowledge that the deceased executed a written instrument pursuant to Public Health Law Section 4201 or a
containing directions for the disposition of his.or her remainsand-Uwe are the petson(s)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:
Male Saltine
"lame aldeosssec
DOS-1898 f(Rev.04/20) Page 1 of 3
0210912021 12:06 (FA)}5187616499 P.0031013
. Authorization for Cremation and Disposition
(Insert from the Hat below)
Number. #6 Description:Appointed Guardian
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 olden
4. A surviving parent;
6. A surviving sibling eighteen years of age or older;
6. A Iawrulty appointed guardian;
7. Any person(s)eighteen years of age or older entitled to share in the estate and who Were closest in relationship to the deceased;
S. 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 ore 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 Pubic Health
Law Section 4201(7).
1 ,,=:ALL THREE of the Mowing)
1111 Me 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
erprior to cremation may result In harm to the crematory and crematory personnel.
/We affirm that instructions have been given to Sarah A.Philo
r unot4 oxrck,rName)
regarding the removal of any personal property or other thing of value which any parson signing below or any family member of the
deceased wishes to preserve. Pine View Crematorium
is not responsible for the removal of personal items from the container or from the remains of the deceased. Personal Items left in the
co - or with the remains will be destroyed by the cremation process and cannot he retrieved after cremation.
Aid iiWe hereby authorize Pine View Crematorium
Punotory )
to cremate the remains of the deceased.
Mitte(OPTIONAL)
I h by authorize a na d funeral director prowl for delivery t d crerna on by an rn
amatory, dee ed recess n the op Ion of the fun r5I director,a this form to a carte na nd
dress uch al nate c story.
FINAL DISPOSITION
The person authorized to receive the cremated remain°of the deceased from the crematory Is:
Name:Singleton Sullivan Potter Funeral Home,Sarah A.Philo
Addres8:407 Bay Road,Queensbury,NY 12804. Phone: (518)793-4459
The cremated remaine of deceased will be disposed of as follows:
To be decided
If for any reason the person named above does not take possession of the cremated remains,
Pine View Crematorium ie authorized to give possession of
rownarwynepay
the remains to Singleton Sullivan Potter Funeral Home by delivery
(NNW
in person or by registered mail. Male Saltine
DOS-1898-f(Rev.04120) Page 2 of 3
0210912021 12:07 (fAX)5187616499 P.0041013
• Authorization for Cremation and Disposition
following)
Apt
I/We understand that lithe remains are not claimed within 120 days of cremation.
Pine View Crematorium may dispose of the remains in
Frame ddemNpryj
an Irretrievable manner,such es by scattering.
CREMATION CONTAINER►URi4
Mod ONE of the following)
Singleton Sullivan Potter Funeral
An um to be used as a bunteiner for the cremated remains has been purchased from l-Inmw
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.
`•adi�
An urn is not yet purchased. I/We understand that If no urn is purchased or otherwise provided
Pine View Crematorium we pace the cremated remains in
Mew of Cle.s
a rigid temporary container for delivery.
This Authorization Form was provided by Sarah A.Philo was executed at
funeral Panto,NSW
Singleton Sullivan Potter Funeral Home
407 Bay Road,Queensbury, NY 12804
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/ere the person(e)in control of disposition,who by signing this Authorization Form,attest(*)
to the accuracy and completeness of the information contained In this Authorization Perm and authorize(s)the foregoing.
Signed this 9th day of February ,Y0 2
Christian Hanchett
}yrawr ,aaxeme
1340 State Route 9, Lake George,NY 12845
(.7i-IQLMrA -C1 4/,f/l adtitc
4— JOANNE °""./
Notary Public,State-of ew York
Registration 01 C06028252
t- Qualified in Warren Coun
`�SK3
S'anaha Phi lb
rmralaegis: x Nimbi
12889
-rlfpanarro,rumetq
Male Saltine
(Mama elOmu.)
DOS-1898-f(Rev.04/20) Page 3 of 3