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Busch-Scardino, Nancy Pine View Cemetery & Crematorium Quaker Road Queensbury, NY 12804 (518) 745-4477 or (518) 745-4476 FUNERAL HOME: J (1)3M0 RETURN TIME: DATE & TIME REMAINS ARRIVED AT CREMATORY: •5'Z7 j Zj NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS: NAME: SlAeAPS/jo CASE # Ll TYPE OF CONTAINER: mikhtyr- AvryirS ��% 4''GI aiLl &y4/ 4(6v f4,A1', PLACE OF DEATH: 6�I tn� �'�(�S 4xsei s l ESTIMATED WEIGHT OF REMAINS & CONTAINER I5 Ir /is PLACED IN HOLD: PLACED IN REFRIGERATION: DATE OF CREMATION: jl TIME STARTED: �� �� A1�I TIME COMPLETED: ' of n l PLACED IN RETORT: tit) MOVED: 2' 36?I I 00lr) RETORT# IN WHICH REMAINS WERE CREMATED: SU ,.� fbwa K 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 NEW YORK Division of DIVISION OF CEMETERIES STATE One Commerce Plaza OPPORTT UNITY_ Cemeteries 99 Washington Avenue Albany,NY 12 2 31-0 0 01 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. 05/27/2021 Date: Number: �tn Crematory Name:.Pineview Crematory . 21 Quaker Road,Queensbury, NY 12804 (518)745-4477 Address: Phone: CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS. Cremation is carried out by placing the remains of the deceased and the container Bolding 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 cremation,the crematory will take reasonable efforts to remove all of the remains and other material from the cremation chamber, but some minimal dust and residue Will likely be left behind. The crematory will separate incidental and foreign material from the remains and the incidental and foreign material will be disposed of as required bily law. The cremated remains will be mechanically pulverized into small pieces and placed into a designated container or urn. Crema d 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 un-cremated human remains in limited circumstances,such as to confirm the identity of the deceased or to ensure that no material is endosed 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 will be done in privacy,with dignity and respect. IDENTIFICATION OF DECEASED Name of Deceased: Nancy Busch-Scardino Marital Status: Separated Last Known Address: 30 Harrison Avenue,#2,Glens Falls, NY 12801 Glens Falls Hospital, Glens Falls,New York Place of Death: I Sex: 0 M ® F Age: 59 DOB: 01/21/1962 Date of Death: 5/24/2021 Estimated Weight: 1�B Description of casket/container in which remains will be delivered. (type/material/model/manufacturer) Matthews Aurora Wood and Cardboard Crema�ion Container �I PERSON IN CONTROL OF DISPOSITION (Person(s)in control of disposition, /n//al ONE of the following) I am/We are the designated agent of the deceased designated in a Will�r written instrument executed pursuant to Public Health Law Section 4201. i I/We have no knowledge that the deceased executed a written instrument pursuant to Public Health Law Section 4201 or a wi ining directions for the disposition of his or her remains and I/we are the persons)having priority under Public Health Law Section 1 and have the right to authorize cremation of the remains of the deceased. My/Our relationship to the deceased is as follows: Nancy Busch-Scardino (Name of Deceased) i DOS-1898-f(Rev. 08/15) Page 1 of 3 Authorization for Cremation and Disposition (Insert from the list below) Number: 9 Description: Close friend/Power-of-attorney/Executor 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 share in the estate ar d who is/are closest in relationship to the deceased; 8. A duly appointed fiduciary of the estate; 9. A close friend or relative who has executed a written statement pursuant to POtblic 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 who is acting on behalf of the deceased and who has executed a written statement pursuant to Public Health Law Section 4201(7). flnitial A.ALL THREE of the following) Me hereby affirm that the body of the deceased does not contain a ba ery,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 the ite prior to cremation may result In harm to the crematory and crema ory personnel. I e affirm that instructions have been given to Robert I.Densmore (Funeral DlrectorNeme) regarding the removal of any personal property or other thing of value which any person signing below or any family member of the deceased wishes to preserve. Pineview Crematory is not responsible for the removal of personal items from the container or from the r mains of the deceased. Personal Items left in the c tainer or with the remains will be destroyed by the cremation process andtannot be retrieved after cremation.i ton. r Me hereby authorize Pineview Crematory (Cremator-)Name) to cremate the remains of the deceased. FINAL DISPOSITION The person authorized to receive the cremated remains of the deceased from the crematory is: Name: Robert 1. Densmore Address:7 Sherman Avenue, Corinth, NY 12822 Phone: (518)654-9285 The cremated remains of deceased will be disposed of as follows: Sent to close friend If for any reason the person named above does not take possession of the cremated]remains, Pineview Crematorium (Crematory Name) is authorized to give possession of the remains to Densmore Funeral Home, Inc. (Funeral Home Name) by delivery in person or by registered mail. Nanc Busch-Scardino (Name of oeceesed) DOS-1898-f(Rev.08/15) Page 2 of 3 l Authorization for Cremation and Disposition (Initia he following) I/We understand that if the remains are not claimed within 120 days of cremation, Pinevie Crematorium an irretrievable manner, such as by scattering. (Name Of Crematory) may dispose of the remains in RE TION CONTAINER/ R (lnif' ONE of the following) An urn to be used as a container for the cremated remains has been purchased from Densmore Funeral Home, Inc. and is scribed as follows: Two basic urn's/included in arrangements 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. -OR- An urn is not yet purchased. I/We understand that if no urn is purchased or otherwise provided Pineview Crematorium (Name or Crematory) will place the cremated remains in a rigid temporary container for delivery. This Authorization Form was provided by Robert I. Densmore (Funeral Director Nana) was executed at Densmore Funeral Home, Inc. 7 Sherman Avenue, Corinth, NY 12822 (Funeral Home Name) (Funeral Home Address) 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/are 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($)t t ore oin 27th g' Signed this day of May 20 21 Elizabeth LaPorte r TYPed or Printed Name � � �✓V� 11726 Wood Lane, Houston, TX 77024 Signatu Address Typed a Prin(ed Namo Signature Address Typed or Printed Name Signature Address WITNESS: Robert 1. Densmore (Funeral Dire:111 1,petl or Printed Name) (Funeral Signature) 10910 ( eg s reaon um e Nancy Busch-Scardino (Name of Deceased) DOS-1898-f(Rev.08/15) Page 3 of 3 :0P Division of �ORTUNITY. rye�Plea' Cemeteries qqw Aft",ar1,112:31,0 r Teleplwrre:(610 4^4226 wwwdft.y Authorization for Cremation and bisposMon This Authorizedon Form must be completed and signed prior delivery of remains for cremation. Date: 05/27=1 Number: Crematory Name:Pineviaw Crematory - Address:21 Quaker Road,Queensbury,NY 12804 Phone:(518)745-4477 CREMA'01 +IS AN,IRREVERSIBLE AND FINAL PROCESS. ' CreiMation is carried 6 by placing the remains of the deceased and the container ing the remains into a cremation- they are subjected to intense heat and flame. The heat and flame will Incinerate ad consume everything except twne,and metal= which are all thatvAli be left after cremation. Farlg.pnsmatton,the.,Crematory w01 take reasonable efforts to rerno+re aU of the sins alyd t>th matenal from the Chamt:iar'W s'eme minimal dust and residue will likely be left behind The crem va sepmft Incidental and 1weign ircatl a , the remains and the inc idental.antl:foreign,metartal:will be disposed of as required , IMw wF araan% Ad rem rrs-wfli#xl . pulverized Into small pieces and:plaoed into a designated container or um. C retrsNris gsetaafb+na pufverb�ad � �.,1°r� �� single fragment is recognizable as skeletal tissue. QMNINQ OF THE COi1MMER The crematory tray only open the container holing the un-c remated hrnnaui , M GmlOsct ideniity of llttaPdeieased'or`to ensure giat`nomaterial is endosetl whklh migttF' �r� ;, f�K�°rs human iSnfgttns are delivered lA a corrtainervrhtch Is notsuitabie for sw��a►� � � � arernstidrywRHi require:thabtl�e rerrwtine be moved in6o s eµitabte contallner i�ae � - r;, Container or the trensferrpnremovsl of remains wiA:be Ccndut�ad,.t>refcr�e.a mess tledi�, Name,df Deceased (Van Busch SCardinos Sp`°Harrison Avenue,#2,Glens Fails NY l Ql T q x t Le*krimn Address. r t PiBre Of Glans Falls hospital.Glens . D69tf1. k. t r + zx a ' a Rf V,u z r � 8 4 d 41 't0+}�' ^"sW 4 1 ) t , y exy Nurnper ci+ose ftland�PavvAr�rf�speep/@csitx m} gneted:in writing pursuant to Public Health Law SWUM 4201(3; 2The ng 2L The si^M�mestic 3 A1y errrWpi gild partrrer, eighteen years of age or older; At►9,pere 3• A untivin8 llbiklg eighteen years of age or older; TA,fe r rated guardian . P� eigfdean years of age or older entrt>erl to share in the estate a who Were closest Inrelationship m the deceased; 8. - 1Ufsrdary of the estate; A friend or relative Who tlae execrated a written statement purssiant to tieelth"Law tfeoUon 4201(7) 10. q �af6cer ofa county or a public administrator a 10a. rogate, C Any.othei parson Who is acting on behalf of the der�ased and wwhha hapUs a wii stafein urt Procedure to F�iibUc Health Law,�on 4r201(7). t hh4reby affirm that the body of the deceased does not contain a bat tery pads,power cell,radioactive implant, or radroa{ $ { any Buds removed prior to the of this Autlwrl�rtlon Farm. Failure to remove tadtatttats'rnay r ow kt how crertw ry and pasamra{. �t tt�lt6ttutsforrs have been gNren ha ? ©r otlser ttng�v oh any, signing below or any famlry member of the d t fen0t' e� btperaarlat.itema^htthe�GF.ttdrntlta �gtedesxlu9sed. f ftie- e <`NK �910�Ow r lradtis t#rbf bdertttOyetd p� t a: 'rri = n r , k r rv, z 4 sk 1 `s sL s, �,. r ,..Ma•�' ;' r� ,�' 6 £fit,•. £ �'ftr,.a•�r r �- t± rYw an. ir: 3� A r Authp INN NEI s+ iiierstand ftf�ff the temakfs are not ckftw wlltkf 120 dep or°' 0n, an i y� such as by . 4�e.as welMgr ►� Of the 1 Brrre�ts in dm be used ap s cOntOw far fffe anenabd ren*m has been pL=tmed from Densmore FWWW Home,fnc Saw j Two lassie dad trt ff fife u n fs too small to hail fhe enw,csmmud mmwrma an edoonaf l mey be Used for delivery. 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