McCann, Susan Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME:
RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: g 130114
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
I(4A-
NAME: .5410) CASE #
TYPE OF CONTAINER: -fli,r4414 4tickit frooct
PLACE OF DEATH: _ . I Is
ESTIMATED WEIGHT OF REMAINS & CONTAINER__________ 200
PLACED IN HOLD:
____________
________ _ _
____
PLACED IN REFRIGERATION:
DATE OF CREMATION:
TIME STARTED: _ '7:20vArl TIME COMPLETED:
PLACED IN RETORT: _ -7: 0111 MOVED: ir Len 54_61
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.
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New York State
Division of DepartmerrtofState
NEW YORK DIVISION OF CEMETERIES
STATE OF One Commerce Plaza
PPORTUNITY
Cemeteries 99 Washington Avenue
Albany,NY 12231-0001
Telephone:1518)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: 12136 itij Number. 7 Z-)
Crematory Name:Pine View Crematory
Address: Z I cJc,r/c,t_ iCn it, .4,2, -f 7 i z 84/ Phone: (Sit) 7N5-K
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,
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 writ likely be heft behind. The crematory win separate incidental and foeign 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 limited circumstances,such as to confirm the
identity of the deceased or to ensure that no material is endosed 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: 5.70 cO. (f,i,ti A) Marital Status: A,A#-A-19 ,
Last Known Address: / 3 a'I us /e _ive
l" ? 3 c �/5 0 �„��l<— /`� /�76
Place of Death: CAni.) T-A// ./Ov 7 (D 4,c-"s / s /(1) 001
Serc D M cgtE Age: £/ DOB:63/&g://f 6& Date of Death: p/a f/20ol_( Estimated Weight:r2OQ
Description of casketk ontainer in which remains/will be delivered.
`�rc.rc¢- tiiA7lTvc� Gl'7 i �- ithre c L) U e A
PERSON IN CONTROL OF DISPOSITION
(Person(s)in control of disposition,initial ONE of the following)
1 are the dash ate a nt of the d ' cited in in pu is
Health w Section 4201.
-OR
r ' -c UWe have no knowledge that the deceased executed a written instrument pursuant to Public Health Law Section 4201 or a
will containing directions for the disposition of his or 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:
SUSAe iit-eAu(None&Deceased)
DOS-1898-f(Rev.08/15) Page 1 of 3
Authorization for Cremation and Disposition
(Insert from the list below)
Number aDescription: sS �Th c s-a--
V
1. A person designated in writing pursuant to Public Heatth 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 is acting on behalf of the deceased and who has executed a written statement pursuant to Public Health
Law Section 4201(7).
(initialin► ALL.THREE of the following)
1 ill)l llWe hereby affirm that the body of the d does not contain a battery,battery pack,power cel radioactive implant,
or radioactive device and that any such materials were removed prior 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.
Fi67% I/We affirm that instructions have been given to ZLJ ()
FFuaeral DirocborName)
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
Mamma:ay 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.
UWe hereby authorize Pine View Crematory
(C+ama asy Name)
to cremate the remains of the deceased.
FINAL DISPOSITION
The person authorized to receive the cremated remains of the deceased from the crematory is:
Name:Any Staff from the Edward L Kelly Funeral Home
1019 US Rt 9 PO Box 548,Schroon Lake,NY 12870
Address: Phone:515.532 7177
The cremated remains of deceased will be disposed of as follows:—
.f&��r-,k TihL)/ /)k N i1 —
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
rcr MryName)
the remains to Edward L Kelly Funeral Home by delivery
(Pones,Home Name)
in person or by registered mail.
SOS /G6A Nii)
(Name of Deceased)
DOS-18984(Rev.08/15) Page 2 of 3
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•
Authorization for Cremation and Disposition
(Initial the following)
61:01-c--- WVe understand that if the remains are not claimed within 120 days of cremation,
Pine View Crematory
may dispose of the remains in
(Name of Crematory)
an irretrievable manner,such as by scattering.
CREMATION CONTAINER/URN
(Initial ONE of the following)
r• um �
Edward��j Funeral .ome
• urn r_
•- used - a •,•• •nerfor Pe cremated Ian_••sh. • •
and s des 'b: . as follows: A . aggil1_ .
INVe • derstand that if the urn is too small to hod! entire ^ -'remains,an additional rigid container may be used for•-' ery.
-OR-
P;/Yy- An urn is of yet purchased. I/We understand that if no urn is purchased or otherwise provided
u /oli E de W ( iN 7 Q 1` ( will place the cremated remains in
(Name or Crematory)
a rigid temporary container for delivery.
K_J
This Authorization Form was provided by t.r.) L (yrax was executed at
(FoxralName)
Edward L Kelly Funeral Home
(Funeral Home Name)
1019 US Rt 9, PO Box 548 Schroon Lake,NY 12870
(Funeral Home Address)
and is signed by the funeral director as witness to its execution.
WVe have received a completed copy of this Authorization Form.
The person(s)identified below islare 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.
Spied this 3o day of /N ul aS I ,20 9. 1
a M Name Signature
�'YI�G,a,uqc� TReR.A.1-1 9); ry‘e-------i/
�, ,/ r
/3a7 V S /f� ( a c 4 i cto u) A I e AV. I 9-(E X:)
A�reu
Typed or Printed Name Signature
Address
Typed or Printed Name Senators
Address A
WITNESS:
--j-;kiu- .---- 147/V lir A
(Funeral Director Typed or Printed Name) !!""..7- Signature) /-----
(Reytsaat(a►ail Yr
SUS A it) fik_e74 iv it)
(lame ofDeceased)
DOS-1898-f(Rev.08/15) Page 3 of 3