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Powers, Robert James Pine View Cemetery & Crematorium Quaker Road Queensbury, NY 12804 (518) 745-4477 or (518) 745-4476 FUNERAL HOME: /I.J , Vh x RETURN TIME; wnrc DATE & TIME REMAINS ARRIVED AT CREMATORY: _��/(j NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS: NAME: RrI er4 ��, �2fS CASE # 52.0 TYPE OF CONTAINER: ill;hIyhti C.r21haii0 (j-;Sk.t-} — (G��erCt _ Cajce� C 14IrdyoiP4 PLACE OF DEATH: `)? Pcfk Utv�vL. �G{-� d;,,,c,r6, 'few ya{k 12'zy ESTIMATED WEIGHT OF REMAINS & CONTAINER_ ISo 175 PLACED IN HOLD: it At-, PLACED IN REFRIGERATION: 9 (43 A;M ho�1 DATE OF CREMATION: 6"-2 d-Or) TIME STARTED: k,(3 Cr-;I-3-1 TIME COMPLETED: J Srj FpN PLACED IN RETORT: IL I) MOVED: I,iO Pr RETORT# IN WHICH REMAINS WERE CREMATED: 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. iiS10 - r 7EWYORJ( NewYorkSUNDivlslan of O•P•rtaantaf tep. PPORTUNITY. DIVISION OF CEMETERIES Cemeteries One Cawmaru Pieta 99 Washington Avenue Albany,NY 12231-0001 TaUphone:Mal 47442241 www_docrir .....-.—u#horization for Cremation and Disposition This Authorisation Fenn must be completed and signed prior so*Ovary of abasing for oremellon, 00/23/2021 li story Name Pine View Crematory Ntsnbar Ss Quaker Road,Ousensbury,NY 12004 „-- —— ---- Phone. 1518.746•4477 REMATION IS AN tRREVERSISLE AND FINAL PROCESi 1 ^~ remabon is carved out by Placing the remains Of the deceased end the container holding the remains into a Cremation chamber where y are subjected to intense heat end name The heat and flame will Incinerate and oonaune everything except bone and metal, ch are all that will be left after cremation. •lowing cremation.the crematory will take reasonable efforts to remove ell of the remains ono other material from the cremation mbar.but some minimal dust and residue wit likely be left behind The• remains and the incrdenlat and foreign materiel will be disposed of es requiredCrematory awit he cram r parate incidental and f°it be ache i from nzed into smell pieces and placed into a d Cremated taw The crammed neat pu er zs�y ngle fragment Is recognisable as skeletal tissue Led eontainpn or um. remains generally ant ptdwriioed until no •'-ENING OF THE CONTAINER crematory may only open the container holding the un-cremated human remains in limited arcumstances.such as to confirm the thy of the deceased or to ensure that no matenal is enclosed which might injure employees or darn h , an remains are delivered In a container which Is not suitable for cremation such as unemo damage or rental metproperty_ S• story will require that the remains be moved into a suitable container before It accepts the remains. The opening of a • , tanner or the transfer or removal of remains will be conducted before a witness and will be done in privacy.mei dignity and neglect- I. -!CATION OF DECEASED Robert James Powers of Deceased 1AIrbM MMus:Never Winked Known Atioisas, 77 Perk Ave.,Fort Edward,NY 12828 • of Death: 77 Park Ave.Fort Edward,NY 12828 Elio ©F Age.71 DOS 11/05/1949 Dais of Death:08/1t3/20Z1 150 Estimated Weight • --• .• • of casket/container in which remains will be delivered. inimum Cremation Casket-Florence Casket Co. Pine/Cardboard RSON IN CONTROL OF DISPOSITION rson(s)in control of disposition,initial ONE of the following) I amANe are the designated agent of the deceased designated in a win or written instruner8 executed pursuant to Pablo H -- I Lew Section 4201 a-- 1/VYe have no knowledge that the deceased executed a written instrument pursuant to Public Health Law Section 4201 or e wi containing directions for the disposition of his or her remains and I/we are the pereon(s)having priority under Public Health Law = bon 4201 and have the right to authorize cremation of the remains of the deceased. My/Our relationship to the deceased Is as fo lows: Robert James Powers pang orPawed) 1..4 S-1898-f(Rev.04/20) Page 1 of 3 � s Authorization for Cremation and Disposition !BIN the rapuwrng) "i``+--+ -- Wile understand that if the remains are not claimed within 120 days of cremation, Pine View Crematory *n irretrievable manner such as M"sofCressloyt may dispose of the remains In by scattering. ONE ION CONTAINER/URN anlha(ONE of the foifowrng) An urn to be used as a container for the cremated remains hes been purchased from and is described as follows. IANe understand that if the urn is too small to hold the entire cremated remains,an additional rigid container may be used for delivery -bR- T 'MP. An urn is not yet purchased. IfWe understand that if no urn is purchased or otherwise provided Pine View Crematory Mr.n.acwn.a,yi will place the cremated remains in a rigid temporary container for delivery This Authorization Form was provided by Todd G.Kilmer (Fior„a„o rMoe) was executed at M.B.Kilmer Funeral Home 62 Broadway.Fort Edward,NY 12828 rums,/Home Addis! and is signed by the funeral director as witness to its execution. Wile have received a completed copy of this Authorization Form. The person(s)identified below Ware the persons)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 a:3v4 day of June ,20 21 Maureen Hirtle perryTold or Thtnied Name 4 Hill Road,Hooksett,NH 03106 'wAmen ore irk GA A MCC'O Notary• Wit-New Hampshire T or Pella Kama Com,,,:s e -txpiros IA19,2022 Mum /Arias WITNESS: Todd G.Kilmer e& (FwM.f D).Ra Typed a.sotlpd AIM.) p4mr l orncdorSip+..my �� • 11679 ir.�'niiom"7wvmeea _ _. Robert James Powers (Nam et Daman* Page 3 of 3 DCS-1898-f(Rev 04i20) Authorization for Cremation and Disposition (Insert from the list below) Number. 5 Description. A surviving sibling eighteen years of age or older 1. A person designated in writing pursuant to Public Health Law Section 4201(3); 3. The surviving spouse, 3a. The surviving domestic partner; 3. Any surviving child eighteen years of age or older 4. A surviving parent: A surviving sibling eighteen years of age or older; 1. A lawfully appointed guardian, ". 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; I. A close friend or relative who has executed a written statement 0. A chief fiscal officer of a county or a public administrator appointed pursuant at Public Health LawteCourt Proc4201edure 0a. Any other person who is acting on behalf of the deceased and who pursuant as executeto d�a wrr�r statement pursuant purrs�u oAPuublic Health Law Section 4201(7) Piglet ALL THREE of the following) 7f1 N 1/We hereby affirm that the body of the deceased does not contain a battery,battery per.power cell,radioactive implant, cr radioactive device and that any such materials were removed prior to the execution of this Authorization Form. Failure to remove mesa items prior to cremation may result in harm to the crematory and crematory personnel, P H IhNe affirm that Instructions have been given to Todd O.Kilmer (Piffling Oraeror Name 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 (Covonitorit not responsible for the removal of Nome) personal items from the container or from the remains of the deceased. Personal items left in the c mtainer or with the remains will be destroyed by the cremation process and cannot be retrieved after cremation. NO" 1Nve hereby authorize Pine View Crematory rQianrloryNaeN) to cremate the remains of the deceased. (Millet 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. Nlrme: M.B.Kilmer Funeral Home Address: 82 Broadway,Fort Edward,NY 12828 Phone: 518-747-9288 The cremated remains of deceased will be disposed of as follows: • If for any reason the person named above does not take possession of the cremated remains, P ne View Crematory is authorized to give possession of (Gamer Nara) th D remains to M.B.Kilmer Funeral Home by delivery (FwM Homo win.) in person or by registered mail. Robert James Powers (Noma N oapare DOS-1898-f(Rev 04/20) Page 2 of 3