Greenfarb, Louis Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: R - 0 S . RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: X /'1 /7/ j �s�h
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
N1(\a,lot 47 5tHOI4E.
NAME: 100LS PPE Et'F tR CASE # Z
TYPE OF CONTAINER: $964c(a ()a - I(fC,res4t% £-.* ,M(
PLACE OF DEATH: 3 V I c( - - 1?044 (<((,c eoory Pa 17 gl1C
ESTIMATED WEIGHT OF REMAINS & CONTAINER $O 1k
PLACED IN HOLD:
PLACED IN REFRIGERATION: 77?"-
2 ) p11DATE OF CREMATION: 'J TIME STARTED: o� TIME COMPLETED: 2•�S�t1
PLACED IN RETORT: a MOVED: ')3
RETORT# IN WHICH REMAINS WERE CREMATED: 0v.e_f` Pc Y I[
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.
New York State
Department of State
FX-INEW YORK Division of �� DIVISION OF CEMETERIES
STATE OFJ- One Commerce Plaza
OPPORTUNITY- Cemeteries 99 Washington Avenue
Albany NY 12231 0001
Telephone (518)474-6226
www.dos ny.gov
Authorization for Cremation and Disposition
This Authorization Form must be completed and signed prior to delivery of remains for cremation.
Date 07/08/2021 Number S�Z
Crematory Name Pine View Crematory
Address.Quaker Road, Queensbury, NY 12804 Phone. (518) 745-4476
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 chamber where
they are subjected to intense heat and flame The heat and flame will incinerate and consume everything except bone and metal,1
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 material from the cremation
chamber,but some minimal dust and residue will likely be left behind The crematory will separate inc dental and foreign material from
the remains and the incidental and foreign material will be disposed of as required by law. The cremated remains will be mechanically
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 l.mited 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 Louis Greenfarb Marital Status. Never Married
Last Known Address 3 Old Post Rd., Lake George, NY 12845
Place of Death:• 3 Old Post Rd., Lake George, NY 12845
Sex ®M ❑F Age: 73 DOB: 12/24/1947 Date of Death 07/08/2021 Estimated Weight 80 LBS
Description of casket/container in which remains will be delivered
Buffalo Casket Company— alt container
PERSON IN CONTROL OF DISPOSITION
(Person(s)in control of disposition initial ONE of the following)
HMM I am/We are the designated agent of the deceased designated in a will or written instrument executed pursuant to Pubi c
alth Law Section 4201
-OR-
I/We have no knowledge that the deceased executed a written instrument pursuant to Public Health Law Section 4201 or a
wile containing directions for the disposition of his of her remains and I/we are the person(s)having priority under Public Health Law
Section 4201 and have the right to authorize cremation of the remains of the deceased. MylOur relationship to the deceased is as
follows
Louis Greenfarb
(Name a'Deceased) _ T
DOS-1898-f(Rev 64:20; Page 1 of 3
Authorization for Cremation and Disposition
(Insert from the list below)
Number. 9 _ Description Agent
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 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:s act ng on behalf of the deceased and who has executed a written statement pursuant to Public Health
Law Section 4201(7)
Initial ALL THREE of the following)
Ki
HMM 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 pnor 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.
HMM i/We affirm that instructions have been given to Mark J. DeSimo_ ne
(Funeral Oneeta!Jame)
regarding the remova 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
4 container or with the remains will be destroyed by the cremation process and cannot be retrieved after cremation
MM INV,hereby authorize Pine View Crematory
(Cremarory 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:
Name Helen Matz
Address 500 Bailtown Road, Building 10, Schenectady, NY 12304- Phone. (518) 388-0941
The cremated remans of deceased wi'I be disposed of as follows
Burial at Evergreen Cemetery- Lake George, NY
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
(C omolory Nome)
the remains to Regan Denny Stafford Funeral Home by delivery
lFunerai Home Nnm^)
in person or by registered mail. Louis Greenfarb
--- (Name of Coconsc,t)
DOS-1898-f(Rev 04/20) Page 2 of 3
Authorization for Cremation and Disposition
,Initial the following)
HMM I/We understand that if the remains are not claimed within 120 days of cremation.
�� Pine View Crematory may dispose of the remains in
(Nome of C•r000ty)
an irretrievable manner, such as by scattering
CREMATION CONTAINERIURN
(Initial ONE of the following) Regan Denny Stafford Funeral
An urn to be used as a container for the cremated remains has been purchased from }Influx
and is described as follows:
I/We understand that if the urn is too small to hold the entire cremated rema ns,an additional rigid container may be used for delivery
-OR-
HMM An urn is not yet purchased. I/We understand that if no urn is purchased or otherwise provided
\
Pine View Crematory will place the cremated remains in
(Name of Crematory)
a rigid temporary container for delivery.
Mark J. DeSimone was executed at
This Authorization Form was provided by rr=umral O'recfor Naomi
Regan Denny Stafford Funeral Home
--- ------ - ;Funere7 Home Name)
53 Quaker Road, Queensbury, NY 12804
(Funeral Home Address)
and is signed by the funeral director as witness to its execution.
llWe have received a completed copy of this Authorization Form.
The person(s)identified below is/are
of the inn ormation contained din this disposition,
by
Form and authorize(s)the foregoing.
t(s)
to the accuracy and completeness
Signed this
8th day of July r
Helen Matz _
S+gnaiure'
Typed or Ponied Name
500 Balltown Road, Building 10, Schenectady, NY 12304-
Address
__ _ _ _ Sgnarure
Piped a•_Pnnkd Name _ ..
AddroSS
7y.t.1 p P%NC(!NdnM ',dr afore
Address
WITNESS: i'�XMark J. DeSirnone Fne(7')2J2
S ----
(Flame Pp,-r r .D .7• yped O PT led IV me
10919
Pegistarboo Nunroe.1
Louis Greenfarb
- - (Name of Deceased)
Page 3 of 3
DOS-1898-t(Rev 04/20)