Andrews, Michael Robert Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: jeZ -14tq RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: /0%4:0 411
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
iopD KtcM Q.
NAME: n�C I4V C 1,NP(1 WS' CASE # s TYPE OF CONTAINER: (gs t 4. 7,4 I fj jad
PLACE OF DEATH: 1 Z5 S4,1(-oy, r 'ut 531, (L, (1303
ESTIMATED WEIGHT OF REMAINS & CONTAINER 750 )
PLACED IN HOLD: /a.;3o P 7/i7/1,0}J
PLACED IN REFRIGERATION: 1045' 441
DATE OF CREMATION: 7//7/2-a).l aa
TIME STARTED: _ Ia;)S pn TIME COMPLETED:
PLACED IN RETORT: )e-?,S Qr MOVED: / 1�,..- - 2
RETORT# IN WHICH REMAINS WERE CREMATED: „So.r pc,Licr
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
erf"NEW YE)RK Divisiondepartment of State
51'ATE OFDIVISION OF CEMETERIES
OPPORTUNITY. Cemeteries One Commerce Plaza
99 Washington Avenue
Albany,NY 12231-0001
Teloohone!(518)474-6226
fikuthorizatiion for Cremation and Disposition' www.dos ny.gov
This Authorization Form must be completed and signed prior to delivery of remains for cremation.
07/14/2021 6-15
sate: _ ___ —„� _ Number:
rematory Name:Pine View Crematory
•ddress:QUaicer Road,Queensbury, NY 12804 518-74.574477
Phone'
____ _
REMATION IS AN IRREVERSIBLE AND FINAL PROCESS. '
e remotion 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 wilt Incinerate and aonsurne everything except bone and metal,
hich are all that will be left after cremation..
oliowing cremation,the crematory will take reasonable efforts to remove all of the remains.end other material from the cremation
• amber,but some minimal dust and residue will likely be left behind: The crematory will separate incidental and foreign material from
t - remains and the incidental and foreign material will be disposed of as required by law. The cremated remains will be mechanically
•ulverized into small pieces and placed into a designated container or urn. Cremated remains generally are pulverized until no
•Ingle fragment is recognizable as skeletal tissue.
PENINO OF THE CONTAINER "-I
he crematory may only open the container holding the un-crernated human remains in limited circumstances,such as to confirm the
h entity of the deceased or to ensure that no material is enclosed which.might injure employees or damage the crematory property. If
urnan remains ere delivered in a container which is not suitable for cremation such as ceremonial or rental casket,the
ernatory will require thatthe remains be moved into a suitable container before it accepts the remains. The opening of a
•ntainer or the transfer or removal or remains will be conducted before a witness and will be done in privacy,with dignity and respect.
f+� -N'TIFICATIQN QF DECEASED
Michael Robert Andrews _ _ _ Divorced
me of Deceased:_ __ W Marital Status' _
I. st Known Address:129 Saratoga Ave, 102,South Glens Fails,.NY 12803 ~` ��
Pace of Death:129 Saratoga Ave, 102,South Glens Falls, NY 12803 �M`—
S x. l ®F Age;73 _ Qom 09/'f 213 947` Date of Death 0;'113/2021 w Estimated Weight 280
D-scription of casketicontainer in which remains will be delivereq.
inimum Cremation Casket- Florence Casket Co. Pine/Cardboard
P •sON IN CQ)yIa L OP DISPOSITION
( erson(s)in control of disposrfron, initiol ONE of the following)
— I amble are the designated agent of the deceased designated in a will or written instrument executed pursuant to Public
H aith Law Section 4201.
-"f?-
:40 l/We have no knowledge that the deceased executed a written instrument pursuant to Public Health Law Section 4201 or a
wi I containing directions for the disposition of his or her remains and I/we are the person(s)having priionty'under Public Health Law
Si t,tion 4201 and have the right to authorize cremation of the remains of the deceased. My/Our relationship to the deceased is as
fo lows:
• Michael Robert Andrews
_� _.__ iran»7CDeu`
DtoS-1898_f(Rev 04/20) Page 1 of 3
•
Authorization for Cremation and Disposition
�`�
'Insert from the 1/st below)
Number: Description: Surviving son
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 chta eighteen years of age or older;
4, A surviving parent:
5. A surviving sibling eighteen year s 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 isiare closest in relationship to the deceased;
8. A duly appointed fiduciary of the estate;
8. A close friend or relative who has executed a written statement pursuant to Public Health Law Section 4201(7);
'0• A chief fiscal officer of a county or a public adrrministrator appointed pursuant to the Surrogate's Court ProceGure Act;
10a. Any other person who is acting cn behalf of the deceased'and who has executed a written statement pursuant to Public Health
Law Section 4201(7).
nitial ALL TWREE of the following)
ipt I _I(We hereby affirm that the body of the deceased does riot contain a battery,battery pack,power cell,radioactive implant,
•r radioactive device and that any.such materials were removed prior to the execution of this Authorization Form. Failure to remove
t a items prior to cremation may result in harm to the crematory and crematory personnel.
r INye affirm that instructions have been given to Stephanie A.Gilman
elniami at Meitner)
r •arding the removal of any personal property or other thing of value which any person signing below or any family member of the
d-ceased wishes to preserve. Pine View Crematory
i not responsible for the removal of (O fl' ryNam•) — ——
personal items tom the container or from the remains of the deceased. Personal items left in the
ntainor or with the remains,will be destroyed by the cremation process and cannot be retrieved after cremation.
;.'; A ifWe hereby authorize Pine View Crematory
(Clemen,y Myna) �--------
to cremate the remains of the deceased.
(Initial OPTIONAL)
1/we hereby authorize the named funeral director to provide for delivery to and cremation by an alternate
c ematory,if deemed necessary in the opinion of the funeral director,and to emend this form to provide the correct name and
a dress of such alternate crematory,
Pi AL DISPOSITION
I e person authorized to receive the cremated remains of the deceased from the crematory is:
N.me: M.B.K►imer Funeral Home
Ai dress:136 Main Street,South Glens Falls,NY 12803 518-745-8116
Phone: _
T e cremated remains of deceased will.be disposed of as follows:
In erred at Gerald BM Solomon Saratoga National Cemetery
If • any reason the person named above does not take possession of the cremated remains.
Pi e.View Crematory
{cve,'ia,r,sy
tea}
Taw-all-km Honor Namni is authorized to give possession of
t remains to M.B.Kilmer Funeral Home
- by delivery teen or by registered mail. Michael Robert Andrews
•
_--1•• (Arprhe of Dom .GI
p S-1898-f(Rev_04/20)Cif
Page 2 of 3
I
Authorization for Cremation and Disposition y "---`~
atow
7niitiaal they hollowing) —
(/' —__... /Ws understand that it the remains are not claimed within 120 days of cremation,
Pine View Crematory
— (nanooT:e,,,,r„y) may dispose of the remains in
an irretrievable manner,such as by scattering.
cREMAYic)N CONTAINER/URN
initial ONE of the following)
An urn to be used as a container for the cremated remains has been purchased from
?d is described as follows- —�� `
.—.___..
i lye understand that if the urn is too small to hold the entire cremated remains,art additional rigid container may be used for delivery.
-k)R..
urn is not yet purchased. iMle understand that if no urn is purchased or otherwise provided
ins View Crematory
~� (Aims, will place the cremated ated remains in
rigid temporary container for delivery.
is Authottitttivn Fprm was provided by Stephane A.Gilman
tFaaeratcieemrName)
�_ Was executed at
;.B.Kilmer Funeral Home
y
136 Main street,South Glens Falls, NY 1280 (Fm'ea(Han*Nome)
(Funerel Horne Address) _---- -.
a id ig signed by the funeral director as witness to its execution.
I/We have received a completed copy of this Authorization Forrn.
T e pei on(s),identi ied 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 authorize(s)the foregoing.
S good this 14th day of July 21
ad Andrews /
iw
y ad or Pnntvd Namo ._.__�._ — • ,`_f
1 699 Middle Rd.East Concord,NY 14055 ''4 `,. ,a
Ad F9 —�
.1.tl urPnrge'tkune
Al Mgt --.—..-.._ _—.._.. .-------
Ty. d or PAated Name "' •-- .—.
&G tarure
Alf.-es. T_�1��
w TNE3.3,'�(� ,1�A^D 161 f).,
(Fu•star I Name) --- i �e ".. - — --
11'0melMeV rSgnatum)
UM.k)
Michael Robert]"Andrews
�' �--- Name of gecweedj ----
(
Os S-1898-f(Rev.04/20) Page 3 of 3
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