Gaudier, Yvonne Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: 3t\ RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: -)11,3114 Doini
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
"ul't 5C µ Fat- t cC UoW
NAME: li t)ONPT_ i\O p ZEQ CASE # (v0i
TYPE OF CONTAINER: (c t.5<e-d c c tkoaq /1ocL,(/ 3f Oi
PLACE OF DEATH: Nut dot arc( rod Scovi, 6l.c r4tL 1 i (1gc3
ESTIMATED WEIGHT OF REMAINS & CONTAINER I° iLc JJ1/P
PLACED IN HOLD:
PLACED IN REFRIGERATION: I] 0 ,O"
DATE OF CREMATION: 7-124//4-c,20,60/
TIME STARTED: /. TIME COMPLETED: 319ifilk
PLACED IN RETORT: MOVED: t,
RETORT# IN WHICH REIGINS WERE CREMATED: ��`,�of 'a.
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.
uthorization for Cremation and Disposition
(Insert from the list below)
Number. 3 Description: Ctilli�hleY
1. A person designated in writing pursuant to Public Health Law Section 4201(3);
2. The surviving spouse;
2a. The surviving domestic partner;
67) 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 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 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).
(Int, LL THREE of the following)
ilIP_ I/We hereby affirm that the body of the deceased does not contain a battery, batterypack, power cell, radioactive
implant,
or ra•SErt e device and that any such materials were removed prior to the execution of this Authorization Form. Failure to remove
th e items prior to cremation may result in harm to the crematory and crematory personnel.
,L4116,,,,
IA* I/We affirm that instructions have been given to Cassia Rafferty#14100
ip (Funeral Director Name)
regar. • 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 is not responsible for the removal of personal items from the container or from the remains of the deceased. Personal items left in the
co:Sb1 er or with the remains will be destroyed by the cremation process and cannot be retrieved after cremation.
'.,
aria I/We hereby authorize Pine View Crematory
Ir
(Crematory Name)
to cremate the remains of the deceased.
I _:` IONAL)
' rtiltii /we hereby authorize the named funeral director to provide for delivery to and cremation by an alternate
T,r a • deemed necessary in the opinion of the funeral director,and to amend this form to provide the correct name and
a• • _ > • ,uch alternate crematory.
FINAL DISPOSITION
The person authorized to receive the cremated remains of the deceased from the crematory is:
Name: Baker Funeral Home Personnel
Address: 11 Lafayette Street, Queensbury, New York 12804 Phone: (518)761-9303
The cremated remains of deceased will be disposed of as follows:
Return to family to be decided
If for any reason the person named above does not take possession of the cremated remains,
Pine View Crematory is authorized to give
(Crematory Name) possession of
the remains to
(Funeral Home Name)Baker Funeral Home
by delivery
in person or by registered mail. 1 I T,',r•
(Name of Deceased)
DOS-1898-f(Rev.04/20) Page 2 of 3
Authorization for Cremation and Disposition
(- a following)
`t I/We understand that if the remains are not claimed within 120 days of cremation,
PI4V\ev� l .re Q
(Name of Crematory) may dispose of the remains in
an irretrievable manner,such as by scattering.
CREMATION CONTAINER/URN
(Initial ONE of the following)
An urn to be used as a container for the cremated remains has been purchased from
and is described as follows:
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.
-0 7,
44W4
An urn is not yet purchased. I/We understand that if no urn is purchased or otherwise provided
,.;
ellA__.
\fe tio ( )re_aviak•al will place the cremated remains in
(Name of Crematory)
a rigid temporary container for delivery.
This Authorization Form was provided by Cassia Rafferty#14100
was executed at
(Funeral Director Name)
Baker Funeral Home
(Funeral Home Name)
11 Lafayette Street,Queensbury, New York 12804
(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(s)the foregoing.
Signed this 2O day of VL) 19 ,20 2 1 1
r� Ins C-►cud'e►�
Typed or rated Name Sig
Address 31C Loci-,hart Motlnion {r, LAVE Geo U P., 1Z `4b
Typed or Printed Name Signature
Address
Typed or Printed Name Signature
Address
WITNESS:
Cassia Rafferty C-Iric
' I(L /3..
(Funeral Director Typed or Printed Name) (Funeral Dir uture)
Funeral Home Reg.#01130
(Registration Number)
\1vorre„ Gnu ,e./—
(Name of Deceased)
DOS-1898-f(Rev.04/20) Page 3 of 3