Kirker, John Alden (2) Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: _____ R,Q S
___ _ _ RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY:
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
-- m Arch ._ �s i Nurpe.
NAME: 79_}'i1) _
CASE #
TYPE OF CONTAINER: 344to (2t ( . A(4-crA4
PLACE OF DEATH: a rriaS
ESTIMATED WEIGHT OF REMAINS & CONTAINER /5-0 1J
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION: ni,(u
TIME STARTED: —_—_-$,"All _TIME COMPLETED: 10:J°t1t1
PLACED IN RETORT: g_/0 MOVED• _. y%!0 '( , t�
RETORT # IN WHICH REMAINS WERE CREMATED: f
o w r1L_.___1_
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
NEW YORK Division of DIVJION OF CEMETERIES
STATE OF One Commerce Plaza
OPPORTUNITY. Cemeteries 99 Washington Avenue
Albany.NY 12231-0001
'elephone:(S113)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: 08/10/2021 Number: gf
Crematory Name:Pine View Crematory
Address:Quaker Road, Queensbury, NY 12804 Phone: (5180 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 ex;ept bone and metal,
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 incidental an foreign material from
the remains and the incidental and foreign material will be disposed of as required by law. The cremated remain will be mechanically
pulverized into small pieces and placed into a designated container or urn. Cremated remains generally are p verized 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 limited 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 rertr<al 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,wit, dignity and respect.
IDENTIFICATION OF DECEASED
Name of Deceased: John Alden Kirker Marital Status Never Married
Last Known Address:141 Aiken Road, Middle Granville, NY 12849
Place of Death:Glens Falls Hospital, 100 Park Street, Glens Falls, NY 12801
Sex: ®M 0 F Age: 79 DOB: 07/08/1942 Date of Death: 08/07/2021 Estim, ted Weight: 150 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)
I am/We are the designated agent of the deceased designated in a will or written instrument execute; pursuant to Public
Health Law Section 4201.
><-OR- J
i/We have no knowledge that the deceased executed a written instrument pursuant to Public Health Lew
will cunt ining directions for the disposition of his or her remains and I/we are the persons)having priority under F ublic HSectionealth Law
or a
Section 01 and have the right to authorize cremation of the remains of the deceased. My/Our relationship to the deceased is as
follows:
John Alden Kirker
(Name or Deceased)
DOS-1898-f(Rev. 04/20) Page 1 of 3
Authorization for Cremation and Disposition
(Insert from the list below)
Number: 108 Description:Executive Director
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 relatidhship 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 420 (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 pursunant to Public Health
Law Section 4201(7).
(Initial ALL THREE of the following)
ilwe 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 prior to the execution of this Authorization Fora . Failure to remove
X
these items prior to cremation may result in harm to the crematory and crematory personnel.
I/We affirm that instructions have been given to Mark J. DeSimone
(Funeral Director Name)
regarding the removal of any personal property or other thing of value which any person signing below or any fanil ly 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
container or with the remains will be destroyed by the cremation process and cannot be retrieved after cremation.
. t:el__X I/We hereby authorize Pine View Crematory
(Crematory 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 at alternate
crematory,if deemed necessary in the opinion of the funeral director,and to amend this form to provide t sie 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:Daniel Murray
Address: 436 Quaker Road, Queensbury, NY 12804- Phone: (518; 793-4204
The cremated remains of deceased will be disposed of as follows:
Return to Agency
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
(Crematory Name)
the remains to Regan Denny Stafford Funeral Home by delivery
(Funerat Home Name)
in person or by registered mail, John Alden Kirker
(Name o/Doomed)
DOS-1898-f(Rev.04/20) Page 2 of 3
Authorization for Cremation and Disposition
(Initial the following)
I/We understand that if the remains are not claimed within 120 days of cremation,
Pine View Crematory may dispose of the remains in
(Name or Crematory)
an irretrievable manner,such as by scattering.
CREMATION CONTAINER/URN
(Initial ONE of the following)
Regan Denrbr Stafford Funeral
An urn to be used as a container for the cremated remains has been purchased from 14,,,,e,
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 1e used for delivery.
-OR-
XAn urn is not yet purchased. INVe 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.
This Authorization Form was provided by Mark J. DeSimone was executed at
(Funeral Director Name)
Regan Denny Stafford Funeral Home
(Funeral Home Name)
53 Quaker Road, Queensbury, NY 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(t)the foregoing.
Signed this 10th day of August ,20 21 , 6
Daniel Murray
Typed or Printed Nemo Signaiure
436 Quaker Road, Queensbury, NY 12804-
Address
Typed or Printed Name Signature
Address
Typed or Printed Name Signature
Address
WITNESS:
Mark J. DeSimone
(Funeral Director Typed or Printed Name) (Funeral 'rector Sig to e) —�
10919
(Registration Number)
John Alden Kirker
iNun,.of Deceased)
DOS-1898-f(Rev.04/20) Page 3 of 3