White, Shirley Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: I3t1O RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: 3/l,1 Z( 2 3
°(n
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
NAME: S El yet ill I/111TE CASE # Z(o Y
TYPE OF CONTAINER: £(t,y44rce bo/- Md'11fJ fOk'
PLACE OF DEATH: 714 .0.4. o t a„s. iI1s
ESTIMATED WEIGHT OF REMAINS & CONTAINER / S O /1 r
PLACED IN HOLD:
PLACED IN REFRIGERATION: 2 LiC 1
DATE OF CREMATION: 3)Iz I Z�
TIME STARTED: /O:IS All TIME COMPLETED: iI'LIS AT/
PLACED IN RETORT: (0-ZO MOVED: it 05 All I
RETORT# IN WHICH REMAINS WERE CREMATED: Coe fb'v 4. .pAV
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.
.
los arsu►s
Authorization for it
Cremation and Disposition arc
One converts Rem 99 Washii� --
Ay.NY 1224'f,
(548)47445228
www.dosnrus
This Aufho.izafion Form must be completed and p to delivmy of"'fins 6 on. 4
Date: � ���21 Number. Oa 6 -(
Crematory Name: Pine View Crematory
Address: Quaker Road, Queensbury, New Park 12804 Phone: i51 74 44??
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation is carried out by placing flte remains of the deceased and the c onta r holding the remains into d
cremation chamber where they are subjected to intense heat and flame.The heat and flag wilt Incinerate and
consume everything except bone and metal,which are all that will be left after cremation.
Fpfl cremation,the c rematory will take reasonable efforts to remove an attic s+errsw xe .
the Crem an chamber, but some minimal dust and residue will be left.behind. It c�rerr wi8"
recaghlEabla
incidental and foreign material from the remains and the incidental and foreign material will be did of as
required law. The cremated remains will be mechanically pulverized into small pieces and placed into a
designated container or urn. Cremated remains generally are pulverized unth no single trait k
as skeletal tissue.
ONE# CEN�iTAiNER
Thee crematory may only open the container holding the un-cremated human remainsin limited circumstan such
as to confirm the of the deceased or to ensure that no material is enclosed which might injure employeesCr
damagecrematory property, If human remains are delivered in a container which Is r sui to foc cremation
such as ceremonial or rental casket,the crematory will requI a that the remains be moved a s rie
A +r before It accepts the remains.The opening of a codainer. or the or removal of remains will be
a aid bore a witness and will be done in privacy,with dignity rand respect.
OF DECEASED
A'lt qe r
ck
F ire: y `etr(iItW-hC 3.i
t C , `, N P11_
{4 2 1 3 Date of Death-3 12.O2.1 E ~ 1
�" whit l remains will be dared:
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c * DI t 8tIT_ION
of the deceased designated in a will or
instrument written executed
t_ Yh� 4t ,at � y
Far s�f y,. 3 ffi A�v''ay" + .exsaged- lol�er ewm Pt 1c Laity
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l+• flr':Ir ,xg „;Y� ar _ dispositiOp or p n
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I am/we are the person(s)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:
(Insert from the list below)
Number: "1 Description: nephew
A person designated in writing pursuant to Public Health Law section 4201 (3);
1 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;
()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;
.,4111,°A close friend or relative who has executed a written statement pursuant to Public Health Law , F b&
10.A chief fiscal officer of a county or a public administrator appointed pursuant to the Surrogates 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§4201(7).
QeMMALL THREE of Me following)
ii1Ne 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
4:-Orrametory personnel•
a hereby affirm that instructions have been given tot *actor nerve) Starr Baker#10159
regard
rsval of any personal property or other thing of value which any person signing below or any family member of the
�i, to preserve. (ate'name) Pine View Crematory is not responsible for
of personal items from the container or from the remains of the deceased.Personal items left in the container or
plosion will be destroyed by the cremation process and cannot be retrieved after cremation.
liffthemby authorize(aetoryname) Pine View Crematory to cremate the
Oasis* tithe deceased.
At 44, if
4-1"44".r"'"r'iuttxwized to receive the cremated remains of the deceased from the crematory is:
{
Phone: 18 761.8343
x$S L i'Ak. Y2F -
a be deposed of as follows:
RAirn tO tan* to be decided
� v - ibovo dm matt poeralasion of the cremated remains,
„.; is authorized to give possession of the remains to
._ r. delivery in perm or by registered mail.
tie
t ram l 23:
a q
r
flab;the fogewitxj)
.- .Wife understand that if the remains are to* within 120 days of cremation.
t rrory name) Pine View Crematory -may dispo of the remains in an irretrl+ rabiia+finer,
such as by scattering,
CREi1AA'1'tQN CON 'A1iNi 1�/URI� t
(Initial ONE of the following)
An urn to be used as a container for the cremated remains has been pub from
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Balser Funeral Home and Is described as follows:
WVe understand that rf the um is too small to hold the entire cremated remains,an additional rigl!c retainer may be used
for delivery.
-OR
�, .x, um has not yet been purchased, WVe end thatif no um is purchased
..
try name) Pine View Cre atoor. will placethe cremated remains in a rigid temporary
container for delivery.
This Authorization Form was provided by t new okado nerve) CAfst i F f i y
was executed at home name) Ba Funeral Home
{funeral hone ae 11 Lafayette Street.Queenstwry.New York 12804 and is signed by the funeral director
as witness to its execution.
ion,
me.have received a completed copy of this Authorization Form.
The person(s) rtltied below Mare the persons)in control of disposition,who by signing this Authorization
fgrtn,attests)tea the accuracy and completeness of the Information+contained In this Authorization Form and
'ems)the foregoing.
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