Goodwill, Hilda Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: hitoz RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: gl7-7/7( 2'0007
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
hil,C146,t httc EQ
NAME: ioo p u1,LL CASE # 3)7
TYPE OF CONTAINER: 'L (}L' Ap4riv1kZ Ca, 8/is`IC tftR0150144)
PLACE OF DEATH: WW. '.C') O F well/
ESTIMATED WEIGHT OF REMAINS & CONTAINER Or 14- //70 iL-
PLACED IN HOLD:
PLACED IN REFRIGERATION: Pn 1
DATE OF CREMATION: LI 1 28)1(
TIME STARTED: 7 )6` TIME COMPLETED: y./Tern
PLACED IN RETORT: 7 1 On MOVED: '6 411 ( y Cc?tri
-
RETORT# IN WHICH REMAINS WERE CREMATED: -19,wuz. PAIL
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.
--_- 1 :59 5186486227 JULIE PAGE 03/05
New York State
Department of State
-1NVW YORK Division of DIVISION of CEMETERIES
S ATt 4P One Commerce Plaza
/ ". Cemeteries 99 Washington Avenue
Albany,NY 12931-0001
.telephone:(518)474 6226
www.dos.ny.gov
Authorization for Cremation and Disposition •
This Authorization Form must be completed and signed prior to delivery of remains for cremation.
-- -- - Number. —- __ --
Pine View C'ematory
"°-a .fir-: Nei--E ---- ---
��cr,rt'_ :.1M�. s' 2i304 —.- -5;874b-4477—. .
Phone:
IS AN IRREVERSBLE AND FINAL PROCESS.
v, *=irrieo out try oiecing the remains of the deceased and the container holding the remains into a cremation chamber where
4-rift ;,-e r,eerse neat and flame. The heat and flame will incinerate and consume everything except bone and metal,
ailimet are ail gnat ail be left after cremation.
,;_ecirie.._. re crematory will take reasonable efforts to remove all of the remains and other material from the cremation
s s- ',inner dust arc residue will likely be left behind- The crematory will separate incidental and foreign material from
1-11 arc Tie dental and forewgn metenal will be disposed of as required by law. The cremated remains will be mechanically 1
rtr sr',d oiebes are:,laced trite a designated container or urn. Cremated remains generally are pulverized until no
v trtrgaaert nt reCOgnizsbie as skeletal tissue A _MC OF' CONTAINER
Ire .,,,-.„ate, yr x'e-Tes ca tta;^-er-ototng the un-cremated human remains in limited circumstances,such as to confirm the
oe- , re Nase-1 r z .re Tat^o material is enclosed which might injure employees or damage the crematory property. If
remains are deetvered in a container which is not suitable for cremation such as ceremonial or rental casket,the
Wratittory.wit require that the remains be moved into a suitable container before it accepts the remains. The opening of a
:..iesyre.. -r&^,e e"ora c!-er:a is w li be conducted before a witness and will be done in privacy,will dignity and respect.
€IIEtf yr-A'f DE DECEASED widowed
• " vv l Marital Status
-" Sip,iriiti-a- N =h Creek NY 12853 - -
_;V.c.'Y-ewr?.4ocre>a -_- . . ._-__.-.
EA.N ''x r Creek -North Creek.NY 12653
4/26/2021 125#
�'� _ = �' ,,, Estimated Weight
Se> ",ego -- y r -_ T 7 �S r �,C. Date of Death; — _
:gee--fix r ."x'tarre^ ,twat- rernan5 wiil be delivered.
s creme on ^tai,er MacDonald Container Go.
PERSON IN CQNTROL OF DISPOSRION
.i e scn(s)in control of disposition.Initial ONE of the following)
i�`___ ... 1 am/We are the designated agent of the deceased designated in a will or written instrument executed pursuant to Public
Law Section 4201.
.t' 1/We have no knowledge that the deceased executed a written instrument pursuant to Public Health Law Section 4201 or a
iQ.. -.ontair>ing directions for the disposition of his or her remains and Uwe are the person(s)having priority under Public Health Law
Se--c'4201 and have the right to authorize cremation of the remains of the deceased. My/Our relationship to the deceased Is as
`oriows Hilda Goodwill
'i,'S-1898-f(Rev.04/20) Page 1 of 3
2E/2E121 1 3:59 5196439227 _11 1- PAGE 04/05
Authorization for Cremation and Disposition
(insert frog the list below) niece
Number: _ Descripti0n: -- — -- — —
t 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.
At. A surviving parent;
5_ A surviving sibling eighteen years of age or older.
E. A!awfully appointed guardian;
1. 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;
A duly appointed fiduciary of the estate:
a. A close friend or relative who has executed a written statement pursuant to Public Health Law Section 42C 1(7);
1t; 'ref fiscal officer of a county or a public administrator appointed pursuant to the Surrogates Court Procedure Health
:C.a Any other person who is acting on behalf of the deceased and who has executed a written statement pursuant
3v Sect on 4201(7).
ALL THREE of the following)
K '- . 1 We hereby affirm that the body of the deceased does not contain a battery,battery pack,power cell,radioactive implant.
-WooaCtve device and that any such materials were removed prior to the execution of this Authorization Fonn. Failure to remove
eves*items prior to cremation may result in harm to the crematory and crematory personnel_
Patricia Miller
ss Once affirm that instructions have been given to F.ma,or ,vao.T)
e+,.sS.y the removal of any personal property or other thing of value which any person signing below or any family member of the
Pine View Crematory
r eceasec ashes to preserve.
'Cn«nmoy Nano)
t ,-z rsipe for the removal of personal items from the container or from the remains of the deceased. Personal Items left In the
coeminer or with the remains wilt be destroyed by the cremation process and cannot be retrieved after cremation_
Pine View Crematory
I/We hereby authorize -------
+y -- (CrtMMto,y Narryi
to cremate the remains of the deceased.
,tom
Vwe hereby authorize the named funeral director to provide for delivery to and cremation by an alternate
=rerriatory,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 DtS?OSmON
The oersor aattiorized to receive the cremated remains of the deceased from the crematory is:
Miler Funeral Hone
NOME
6357 NYS Rte.30.Iidian Lake.NY 12842 Phone: 518-648-0011
- —
- crenated remains of deceased will be disposed of as follows'.
sr-,at St.JoSeph s Cemetery.Waterford. NY
€te any reason the person named above does not take possession of the cremated remains.
view Crematory
_ is authorized to give possession of
—. .�. fGnn+eroe NMw) _-
-
Miler Funeral Home _by delivery7te remains to —. �Ol -- - — -
rF ei a/4 r Goodwill
person or by registered mail. Hone
_. ',damn chi n;n.
DOS 888-f(Rev.04/20) Page 2 of 3
13: 5y 5186486227 JULIE PAGE 05/05
Authorization for Cremation and Disposition
e i tcwv,gi
- t o urx erstand that if the remains are not claimed within 120 days of cremation,
i ie .'Q*i27e-neaiory may dispose of the remains ir,
r-e-e.ra a '*tanner,such as by scattering.
CRENATIOI4i COHfTAnNERNRN
ONE of re ioltowing) Miller Funeral Home
urn to oe used as a container for the cremated remains has been purchased from _
and s oesaitec as follows. T 7YOr1
,Vie "-de-stand that if the urn is too small to hold the entire cremated remains,an additional rigid container may be used for delivery.
Ar um is net yet purchased. I,We understand that if no urn is purchased or otherwise provided
sw',"tcw C•etnatory
will place the cremated remains In
Nrrno Or CAmetnry.
"e-r to -sc pry oortaro for dei1v ry.
Patricia Miller _was executed at
-<Authorization Form was provided by -- —
(Funeral oreoln'
A I l 4+G►11 -
(FUnnral Home Hemel
�3357 tiO.S R-e. 30. ?nCan Lake. NY 12842
�_— __-__. -___.. ___-_� inwro�Fkrrn g�o6sr ---
a•,;,s screed b the hirers;direc'!of as'Mtre-3c to its execution.
-e+ veC a c-npieted copy:of this Authorization Form.
'rho pen:ancsl idefttffed bestow isiare the person(s)in control of disposition,who by signing this Authorization Form,attest(s)
is The accuracy and completeness of the information contained in this Authorization Form and authorizes)the foregoing.
25 Apt 2+
this day of '20 - -' �/ /
� x 3dE Lake NY 125.42.
- --raRen Vasa --- - S iv nrrrr - _
'aa3 wr s S.gryner
_ —_= — • — —
t#ifTfIESS:
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a9.r.."Jos mi a ricer-
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--ids Goodwill
-
Waco et oeeeeieZe— .
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