Pope, Joan Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: tQ RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: 4/1-2 1,'20117
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
e'rtiry Iluca
NAME: 30AG) 'f-P CASE #
TYPE OF CONTAINER: cc�U,,,u C` ^� j' t�W; 1>i,K Cgzafe
PLACE OF DEATH: fft ?<n J_ P /J ML
ESTIMATED WEIGHT OF REMAINS & CONTAINER ISO IL 2P
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION: (PM lA
TIME STARTED: /04 TIME COMPLETED: I1'OM
PLACED IN RETORT: /0:)D ' I MOVED: /'' 16' l 'l l
RETORT# IN WHICH REMAINS WERE CREMATED: S` Pw'ea-R}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.
NEWYORK Division of r"(Vrr-7a;
STATE:OF -
OPPORFUNITY Cemeteries
Authorization for Cremation and Disposition
This Authorization Form must be completed and signed prior to delivery of remains for cremation
Date: 6/6/2021 Number (Gg
Pine View Crematory
Crematory Name: - _•
Quaker Rd.,Queensbury,NY 12804 51 f-74c 4 i
Address: Phone
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 rr,arnr,•r
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 matenal from the cremation
chamber,but some minimal dust and residue will likely be left behind. The crematory will separate incidental and foreign material fro-,
the remains and the incidental and foreign material will be disposed of as required by law. The cremated remains will be mecilanicait/
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 un-cremated human 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 will be done in privacy,with dignity and respect
IDENTIFICATION OF DECEASED
Name of Deceased: an Pope Marital Status:Divorced
Last Known Address: 395 Judson St.,Canton,NY 13617
Place of Death: Rochester General Hospital,Rochester,NY 14621
Sex: ®M ® F Age: 80 DOB: 8/16/1940 Date of Death: 6/5/2021
Estimated Weight: 180
Description of casket/container in which remains will be delivered.
MacDonald Container;basic cardboard cremation container;no Interior
PERSON IN CONTROL OF DISPOSITION
(Person(s)in control of disposition,initial ONE of the following)
I am/We are the designated agent of the deceased designated in a will or written instrument executed pursuant to Public
Health Law Section 4201.
-OR-
UWe have no knowledge that the deceased executed a written instrument pursuant to Public Health Law Section 4201 or a
will containing directions for the disposition of his or her remains and I/we are the person(s)having pnonty 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:
Joan Pope
(Name of Docoa,=ki,
DOS-1898-f(Rev.04/20) Page 1 of 3
--
Authorization for Cremation and Disposition
(helot the followrrxl)
4, I/W'under,t.inrt that ii tin rr.rrrsrr1' .an=rrr4 r
[me Viow Crematory
an irretrievable mariner such as by'r ttr,nng
CREMATION CONTAINER/URN
(Initial ONE of the following)
An um to be used as a container for the cremated remains ha been p,;r;r,a0,eri' ." ) I f >r(aL►taifcj
and is described as follows_ C__
IfWe understand that if the urn is too small to hold the entire cremated remains,an additwna:r,ryt ,r, ,ia r "'
-OR-
An urn is not yet purchased 1/We understand that if no urn is purchased or otherwise prripuer:
Pine View Crematory
wr!i pears:the
'ham°o!Crematory:
a ngid temporary container for delivery.
This Authorization Form was provided by Patricia Miller
(Funeral ArrUos Name) .....
Mdie'Firrarri Hr ma
(Funeral Hone Name)
6357 NYS Rte. 30 Indian Lake, NY 12842
Funarm'Home Addmss)
and is signed by the funeral director as witness to its execution.
UNVe have rece.vej 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,attests:
to the accuracy and completeness of the information contained in this Authorization Form and authorize(s)the foregoing
Signed this F day of ,tune ,20 21
Vc,r
—_ �t �r`c fir. \\ rLCerne Sqtrrature
512 or T ue Caul! Myrt;e Beach.Sc 2452E ----,
AJdm`r
WITNESS:
Patricia Mtlier
oma.r-yr*e)^"f'n ...^I:amv,.
,2465
=eg,srano,.
.can r'cpe
- _ (Name of Otec1a>c0
DOS-1898-f(Rev 04,'20) P<aye 3 or
Authorization for Cremation and Disposition
(Insert from the list below)
Number 3 Description•
1. A person designated in writing pursuant to Public Health Law Section 4201 L3)
• 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 and who is/are dose;t in re<<r?rr-h;p!•)ehr,
8. A duly appointed fiduciary of the estate,
9. A close fnend or relative who has executed a wntlen statement pursuant to Public Health Law Section 4201(/)
10. A chief fiscal officer of a county or a public administrator appointed pursuant to the Surrogate's Court Procedure f•.r.t
102. Any other person who is acting on behalf of the deceased and who has executed a written statement pursuant t,Piii.lr..=waits
Law Section 4201(7)
(Initial ALL THREE of the following)
I/We 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 crematory personnel.
Patricia Miller
Me affirm that instructions have been given to
(Funeral Omar,'Nome)
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. Pine View Crematory
(Crematory Name)
is not responsible for the removal of personal items from the container or from the remains of the deceased. Personal items left in the
container or with the remains will be destroyed by the cremation process and cannot be retrieved after cremation
I/We hereby authorize Pine View Crematory
(Crematory Name)
to cremate the remains of the deceased.
(Initial OPTIONAL)
I/we hereby authorize the named funeral director to provide for delivery to and cremation by an alternate
crematory,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 DISPOSITION
The person authorized to receive the cremated remains of the deceased from the crematory is:
Miller Funeral Home
Name:
6357 NYS Rte 30. Indian Lake, NY 12842 518-648-0011
Address: Phone:
The cremated remains of deceased will be disposed of as follows:
burial in Blue Mountain Lake Cemetery
If for any reason the person named above does not take possession of the cremated remains,
Pine View Crematory
is authorized to give possession of
(Cre•na!ory Norse)
Miller Funeral Home bydelivery
remains to
(runertst Home Name)
in person or by registered mail Joan Pope
DOS-1898-f(Rev.04/20) Page 2 of 3