Fuller, Veronica Ruth Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: (713 k,T✓h4/ RETURN TIME: 11O1'L
DATE & TIME REMAINS ARRIVED AT CREMATORY: '5/7-11Zo2/
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
4)9/ $1
NAME: Ue(OltiUti, 71-1.4- (i, )47 CASE # My
TYPE OF CONTAINER: mih rvk..,w 6rl;441#I: t 1- 'Pope 'd lrxe/Libe,,,e/
PLACE OF DEATH: 6ie.15.6,/ii Ge,CIiV 16zsbe, h. e Q+� ��y Nyfy
ESTIMATED WEIGHT OF REMAINS & CONTAINER 15,E/hi Sc Jed ' i /45.
PLACED IN HOLD:
PLACED IN REFRIGERATION: S- "-20 Z/ 2-/lc?.vI
Z DATE OF CREMATION: �-2s- O"I/
TIME STARTED: 73d -► TIME COMPLETED: /0 ZOO
PLACED IN RETORT: D 7 3047,1, MOVED: D 9/ 5 ii
RETORT # IN WHICH REMAINS WERE CREMATED: S ' A./C
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE:THE CREMATION LOG SHALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
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NEW YORKDivision
New York Sate
� v i s i o n Department of State
STATE OFF DIVISION OF CEMETERIES
OPPORTUNITY i f
Cemeteries One Cernmer{e blaze
99 Wash rrmen Avenue
Alberti,NY 12221-0001
_ Tele0h0ea:f518)4746226
Authorization for Cremation and Disposition ""`�--- +~�w•aos-ny,gcv
This Authorization Form must be completed and signed prior to delivery of remains for cremation.
Date:05/2112021
_ — Number. — L`L_lei LI
remetory Name.Pine View Crematory
ddresy Quaker Road,Cutenstx,ry,NY 12804 '�'
,— ;none: 518-745-447>
mREMATION 1$AN IRREVERSIBLE AND FINAL PROCESS.
remotion is Lesreed out by placing the remains of the deceased and the container holairtg the remains into a cremation
--
chamber
hey are subjected to intense heat and flame, The heat and frame will incinerate and consume everything except bone andmetal,
hich are al that will be left after cremation.
orlowing Cremation,the crematory will take reasonable efforts to remove ai;of the remains and other material from the crematon
'iarneer,but some minima)duet and residue will likely be left behind, The crematory will separate incieentai and foreign material from
he remains and the Incidental and foreign material will be disposed of at required by law. The cremated remains will ee mechanically
ulverized into small pieces and o1aosd into a designated container or urn. Cremated remains generally are pulverized until no
Ingle fragment is recognizable as xkaietel Serous,
PENIntr OF THE CoNTAIR
e crematory may only open the container holding the un-Cremated human remains in Iimtrad Circumstances,such as to confirm the
i nbty of the deceased or to ensure treat no material is enclosed which might injure employees or damage the crematory property, if
uman remains ere delivered in a container which Is not suitable for cremation such as ceremonial or rental casket,the
4remstory will require that the remains be moved Into a suitable container before it accepts the remains. The opening of a
container or the tansfer or removal of remains will be conducted before a witness end will be done in privacy with dignity and respect
iENrIFICAT1ON OP DECEAeEQ
care aDeceased: Veronica Ruth Fuller
eNorced
St Known Address:8 Grand Eivd South Glens Falls, NY" Merits(Status:12E03 —
Place of Death Glens Falls Center 152 Sherman eve,Glueensbury, NY 17.t304 ~� _�
seX: Om or Age;7� _ 8130/�943 — _._.��____- ---_..._
Doe Date ar Death;S/2 1.2021 150
_ • estimated Weight;
Clescripoon of oesketiccntainer In wheel remains will be delivered.
inimum Cremation Casket- Florence Casket Co, pine/Cardboard
v___
• .12 a►. N CONTRO 0 e 1'c SFOSiuQN
ee reon(s)in control of disposition, lrvr4/ONE of the foircrwing!
---- I amlWa are the de igneted agent of the deceased designated in a will or written instrument executed purnuantto Public
-alth Law Section 4201.
IMe have no knowledge that the decsased executed a written instrument pursuant to Public Health Law Section 4201 or a
ie II oortaining directions for the disposition of his or her remains And Itwa are the cerson(s)having priority under Public Health Law
S-ction 420e and have the right to authorize cremation of the remains of the decvssed. My/Our relationship to the deceased is as
r.;lows:
Veronica Ruth Fuller
a S-189984(Rev. 04/20)
Page 1 of 3
'.Y. i�� i !I'��( ',iQ. tail i. _
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lA orization for Cremation and Disposition
�� ..�.� _ ..
(insert fro.^ the list bniow)
----- �..,�-
Nurtrber. 5 w OescRption;•A surviving sibling eighteen years of age or bider
1.. A person designated in writing pursuant to Public hirrelth Law Section 4201( _� d
2. The surviving spouse: 3):
i2a, The sur✓iving domestic partner:
13. Any surviving child eighteen years of age o,•older;
14. A surviving parent;
p. A surviving sibiing eighteen years of ace or order:
• P.lawfully appointed guardian;
Any person(s)eighteen years of aye or older entitled to share in the estate,and who israre closest in relationship to the deceased:
A duly appointed fiduciary of the esiahe
A cities friend or relative who has executed a written statement pursuant to Public Health Law Section 4201;7)
0, A chief fiscal officer ct a Cou my or a public administrator appointed pursuant to the Surrogates Court Procedure Ace
Oa. Any ether person who is acting on beha;f of tie deceased and who has executed a written statement pursuant to Publi:Heald
Law Section 4201(7).
'b1ba1 ALL Th-REE of thcs following)
` , ' Wie hereby atf,rm that the tOdy of the deceased doea not contain a battery, battery peck. dower cell, redioartivo implant
r rsdiot-tire device and hat any such rnatena's were remo✓ed prior to the execution cf this Authorttation Form Failure to remove
titese items prior to cremation may result in harm to the crematory and crematory personr.er.
if
- _ irlh't±affrm that instructions navebean given tC Morgan T.Wicks
...... -- !>I:;�sTirrec7or,va,ne)
reyarding the romovw of any nerednal properrrr or other thing of va ue which any pertton is fining below or any family m rybsr of tore —
c�ec:a:seq wishes to prose ve P+ne View Cr,a r story
not responsit1B for Ate r6rrr)'✓dt of nersonal!test$from'!he 3Ontainer or loom the rerr dins cf the des tied• r'erbonpl items left Li the
ntalner or with the remains will be destroyed by tilt cremation process and Cannot be retrieved after cremation.
�` �~� Pine View Crematory�` l/YYs herabygutitorizo__ �-• -�- --
i_ itia/OPTIONAL)
to cremate the rernairis of the deceased.
Uwe hereby aOlin_rize the names;funerai director to provide for delivery to and cremation by an alternate
c ernatary,if deemed noor,gsary in the oplrilorr of the funeral director,and to amend this form to provide the correct nanie and
a dress of suet alternate cr'wrnatory.
F NA i la SiT:ON
T 8 perso,`,authorized to rece ve the cremated remains:�tiho deceased from the e.errratory is:
i
Npm9 M,s.Kilmer fun:ral Hcr!e
4�6ress 136 Main Streit,Stautn Gier,s Hags, NY 17Hp3 .�.�-._ �-- — -.
_ ---.._.,. _.� phon : s 1 F3-745-K t 1 ti
'lie,creniated rerr,ems of deceased will be disposed of its fdilowa: :. -�--����
If or any reason the person lamed abo:.e doe not take possession of the cremated remains. � � �
P s View Crematory
- ----- re - __.,_.----- r`'oromsav Rw _..__........
� a authorized to give possessoo of
th remains to -E Kimer FunFoal Home
in f Pr .__�•._. . --- -Rvnantrko i Nimes -_ by de v9N
p-sc•n or t+y registered med. Veronica Ruth Fuller
D(itis-1898-f(Rev. 04120)
Page 2 of 3
Va y, L I. L;IG I r I-q; y;, !JV
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I
Authorization for Cremation and Disposition
— —IM/e understand that If the remains are not claimed within 120 days Of cremation,
Pine View Crematory
n it*etneveble rnanner.Such as by scattering. (Iv& act° A may disposa of tha remains in
'RE TION CONTAINPR/URN
? i i !ONE of the following)
1 An urn to be used as a r_ontalner for the cremated remains has been purchased from
arm is described as follows:, Jy
i}We understand that if the um Is too sma(I to hold the entire cremated remains,an additional rigid container maybe useddelivery.
fI for del.very-
-0,4-
Cc-
_.,� An urn is not gat purchased I/We understand that if no urn Is purchased or otherwise cro'vided
.111-4"ino Vew Crematory
notary!"" — - --- MI(p'aGe the cremated remains in
a rigid temporary container for delivery,
is Authorization Form was provided by Morgan 7,Wicks
B. i(Irngr Fun4ral Home (funeretGn►_rsn4rn0 was executed at
(costar Name h'anyt) ------b6 Main Street, South Glens Faits, NY 128o3 _ M� '� ' - -'
1
»c h ngAcWSrs) -
and is signed by the funeral director as witness to its execution,
tV+e have received a completed copy of this Authorization Form.
7 e person(;)identified below fsiare the person(s)In control of disposition,who by signing this Authorization Form,sttestls)
to the accuracy anti completeness of the information contained In this Authorization Form and authorize(*)the foregoing.
21 st
Si nod this day of May_ _ 70 21 i r�
C. ffore Fuller j n
0.-Printed Alm
5O Bow N A row Loop, Irtverne�g FL 34452 1 y #^� r
g8»uve
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S�pnafurp""'""
WI NESS:
M gaLI
Wicks
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IR Ha»horreaIi -- --
Veronica Ruth Fuller
C-O$.1698--f(Rev, 04/20)
Pegs 3of3