Halstead, Anna M. Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: fib �Z(M _ RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: _ Walt/ '1)Ph
i
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
Tt n HuRPKy
NAME: OM SST CASE # 524
TYPE OF CONTAINER: 171,90 ,e4f. to. /t #Joajt(
PLACE OF DEATH: if•G I4\5{4N
ESTIMATED WEIGHT OF REMAINS & CONTAINER_ ISO (Le,
PLACED IN HOLD:
PLACED IN REFRIGERATION: 1ttph
DATE OF CREMATION: (ol?si1L qQ
TIME STARTED: - TIME COMPLETED: I Z
PLACED IN RETORT: 7' 14Pil r MOVED: $: 3S pin ' 11•/90
RETORT # IN WHICH REMAINS WERE CREMATED: Su f" fovea- OW
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.
Utj-L4- L I IV:4Lti r rum- -1.:i r vvvc/ %ry r i _c�u
New York State
Z:lisowSTATEEW YOState
RK Division of DepartmentNOFCEMTERIES
OF DIVISION OR CE:M6TERIES
OFTUNITY. Pens
Commerce Pe
Cemeteries 99 Washington Avenue
Albany.NY 12.231-0001
Telephone:(51e)47.46226
wwN.dos.fy.gov
Authorization for Cremation and Disposition
This Authorization Form must be completed end signed prior to delivery of remains for cremation.
Number;
Crematory Name;Pine View Crematory
•.dress•Quaker Road,Oueensbury,'NY 12804 _._T Phone: 518-745-4477M _ `��
REMATION 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 chamber Where
t ey are subjected to intense heat and flame. The heat and flame will Incinerate and consume everything except bone and metal,
P ich are all that will be left after cremation.
F.tiowing cremation,the crematory will take reasonable efforts to remove all of the remains and other materiel from the cremation
amber,but some minimal dust and residue will likely be toff behind. The crematory will Separate incidental and foreign material from
t' e remains and the incidental and foreign material will be disposed of as required by law, The cremated remains will be mechanically
i p iverized into small pieces and placed into a designated container or urn. Cremated remains generally are pulverized until no•
i s nole fragment is recognizable as skeletal tissue:
•'• _NI •F THE CONTAINfil
7 e crematory may only open the container holding the un•cremated human remains in limited circumstances,such as to confirm the
i.-ntity of the deceased or to ensure that no material is enclosed which might injure employees or damage the crematory property. tf
h man remains are delivered in a container which is not suitable for cremation such as ceremonial or rental casket,the
c amatory will require that the remains be moved Into a suitable container before It accepts the remains. The opening of a
c4 ntainer or'the transfer or removal of remains will be conducted before a witness and will be done in privacy.with dignity and respect.
I• _NTIF1C• ON OF • E•
N.me of Deceased;Anna M.Halstead —... M• ._.. Marital Status: widowed `
L et Known A4dresa:4573 NY 40,Argyle, NY 12800(Washington Center)
P=ce of Death:
Washington Center "—____ __..._
S•x: rim 0 F Age:98 Doo.07/29/1922 Date of Death:°612312021 !^ 150
�r . _._. __..� Estimated Weight:
D.scription of casket/container in which remains will be delivered.
Inimum Cremation Casket - Florence Casket Co. Pine/Cardboard
p' .SON IN CONTROL OF D1 ,POSIT/QN
(-,rson(c)in coritrol of disposition,initl//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
H:alth Law Section 4201.
..;•,' I/We have no knowledge that the deceased executed a written instrument pursuant to Public Health Law Section 4201 or a
fell i'ddti:fit'frig directions for the disposition of his or her remains and I/we are the person{s)having priority under Public Health Law
S•otion 4201 end have the right to authorize cremation of the remains of the deceased. My/Our relationship to the deceased is as
fo tows:
Anna M. Halstead
D 5-1898-f(Rev.04/20) Page 1 cf 3
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Authorization for Cremation and Disposition
(fusel from the list below)
3 Surviving daughter
Nuntbet:_µ _ Description: _ __ .__._ � _�. .v
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 and Who ielare Closest in relationship to the deceased;
8, A duly appointed fiduciary of the estate;
8, A close friend or relative who hes executed a written statement pursuant to Public 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),
(Iltitia/ALL THREE'of the following)
..,r ,I/We hereby affirm that the body of the deceased does not contain a battery,battery pack,power cell.radioactive implant,
lki i ";ilsir;
o"radioactive device end that any such materials were removed prior to the execution of this Authorization Form, Failure to remove
t ese items prior to cremation may result in harm to the crematory and crematory personnel.
t„mt f Ws affirm that instructions have been given to Todd G.Kilmer
Itq '� _ .....
• '•- 7�tlr+Yra)Q'+bC.'Qr NdnNd
r carding the removal of any personal property or other thing of value which any person signing below or any family member of
d ceased wishes to preserve. Pine View CrematoryMA
i'not responsible?or the removal of personal Items from the container or from tine remains of the deceased. Personal items left in the
the—
e ntdlner or with the remains will be destroyed by the cremation process and cannot be retrieved after cremation.
�ii.. ..f.. l/We hereby authorise Pine View Crematory
(..: 7E. u (Cr�rnatay M1amrJ
to cremate the remains of the deceased.
(i dial OPTIONAL)
Uwe hereby authorize the named funeral director to provide for delivery to and cremation by an alternate
a matory,if deemed necessary In the opinion of the funeral director,and to amend this form to provide the correct name and
a dross of such alternate crematory.
P Af DISPO'S1TION
T e person authorized to receive the cremated remains of the deceased from the crematory is;
el me M.B.Kilmer Funeral Home
A dress: phone:Broadway,Fort Edward, NY 12828 V✓ 518-747-9288 F��A
The cremated remains of deceased will be disposed of as follows:
G yen to Norman Pitt — _ »If or,any reason the person named above doss riot take possession of the cremated remains,
�...
P e View Gernatory is authorized to give possession of
(t.Nrn ety',Wrist)
tht remains to M.B.Kitrner Funeral Horne_....�..,._.. ..____..._ _.._ ov delivery
,rvonru)none Namo)
in person or by registered mail, Anna Halstead
tVaAW OrGecesrse/
DOS•1898-f(Rev.04/20) Page 2 of 3
•
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Authorization for Cremation and Disposition
(.pItio)the following)
.fu e. ' I/We understand that if the remains are not claimed within 120 days of cremation,
l•-�,P' fryfiw'
1 e,v Crematory
- _ _may dispose of the remains in
rNama ofCramat,y)
Sn irretrievable manner,such as by scattering.
cRFMATIQN CONTAINER/URN
(nitial ONE of the following)
An urn to be used as a container for the cremated renialns hes been purchased from w
d is described as follows;
i e understand that if the urn is too small to hold the entire cremated remains,an additional rigid container may be used for delivery,
- R-
,An urn is not yet purchased. I/We understand that if no urn is purchased or otherwise provided
c j(t,iI ',Crematory
_ - ..w_ will place the cremated remains In
;Name o!GvriNoory)
al rigid temporary container for delivery.
Todd G. Kilmer
l is Authorization Form was provided by ,,,,.„._:,.. ..._....... _.__. __ was executed at
(Apra st o,rootpr NKr*
.8.Kilmer Funeral Home
(ruhota!stoma Namn)
:2 Broadway,Fort Edward,NY 12828
(Nov*,none merom6)
a d is signed by the funeral director as witness to its execution,
I e have received a completed copy of this Authorization Form.
e person(s)identified below is/are the person(s)In control of disposition,who by signing this Authorization form,attest(s)
t the accuracy and completeness of the Information contained In this Authorization Form and authorise(s)the foregoing.
S gned this 24th day of June µ^` ,20 21
adina;Pitt
7. -aOlPEW mama �f.
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%1 Buckberg Mountain Rd,Tomkins Cove,NY 10986
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14 dd G,Kilmer , totar.
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1 879 Mm,
i Anna M. Halstead
(Ndma Of Docoasod) •~
U S-1898-t(Rev.04/20) Page 3 of 3
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