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Frasier, Walter NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records 7r73c Name First Middle Last Sex Walter Doyle George Frasier Male Date of Death Age If Veteran of U.S.Armed Forces, 10/08/2021 81 Years War or Dates c Place of Death Hospital,Institution or City,Town or Village Saratoga Springs Street Address Saratoga Hospital Manner of Death ©Natural Cause ❑Accident ❑Homicide El Suicide ❑Undetermined El Pending W Circumstances Investigation gMedical Certifier Name Title 0 Mikhail Mavashev MD Address 211 Church St,Saratoga Springs,New York 12866 Death Certificate Filed District Number Register Number City,Town or Village Saratoga Springs 4501 580 ❑Burial Date Cemetery,Crematory or Facility Name 10/12/2021 Pine View Crematory ❑Entombment Address Cremation Queensbury,New York ElDonation 0 ❑Removal Date Place Removed and/or and/or Held f— Hold Address N 0 O. Date Point of d) ❑Transportation G by Common Shipment Carrier Destination Date Cemetery Address ❑Disinterment Date Cemetery Address ❑Reinterment Permit Issued to Registration Number Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596 Address 407 Bay Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom 1.. Remains are Shipped,If Other than Above 2 Address Ir W 0. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/12/2021 Registrar of Vital Statistics John Pau(Franck(E(ectronica(lySigned) (signature) District Number 4501 Place Saratoga Springs, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ' W l (address) l Date of Disposition /0I R 17( Place of Disposition in e t f..� ret d r*,--- W IL (section) i (lot number) (grave number) +t Name of Sexton or Person in Charge of mises h1. — 441 z (p({ase print) / W Signature / Title `���"�`'1( DOH-1555(07/18)p 1 of 2 ` 15222 Public Health Law Sec. 4145(2b) 1 Receipt 1 Human remains of , , - delivered on 20 Pine view Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg. or License# - Pine View Cemetery & Crematorium Quaker Road Queensbury, NY 12804 (518) 745-4477 or (518) 745-4476 FUNERAL HOME: S. P _ RETURN TIME: .... DATE & TIME REMAINS ARRIVED AT CREMATORY: _ . ./6/1111,4_/0e3ritil. NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS: %Bo NAME: EP:its:az, CASE II 8.C'C _ TYPE OF CONTAINER: _ . .. PLACE OF DEATH: _ s k_c2_7y. ESTIMATED WEIGHT OF REMAINS & CONTAINER PLACED IN HOLD: ___ PLACED IN REFRIGERATION: DATE OF CREMATION: ...It.I ( _ ... TIME STARTED: th.c /11_ TIME COMPLETED: -2-24‘17p/,'N PLACED IN RETORT: All _MOVED: RETORT U 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 RE RETAINED IN THE PERMANENT FILE OF THE CREMATORY. - New York State Department of State ff-iNEW YORK Division of DIVISION OF CEMETERIES STATE OF 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: 10/08/2021 Number: SST. Crematory Name:Pine View Crematorium Address:51 Quaker Road, Queensbury, NY 12804 Phone: (518) 745-4477 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 will likely be left behind. The crematory will separate incidental 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 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 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: Walter Frasier Marital Status: Married Last Known Address:35 Snowberry Road, Malta, NY 12020 Place of Death:Saratoga Hospital, 211 Church Street, Saratoga Springs, NY 12866 Sex: DM 0 F Age: 81 DOB: 01/10/1940 Date of Death: 10/08/2021 Estimated Weight: Descri 'on of casket/container in which remains will be delivered. co1/44-j\rpoj 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 executed pursuant to Public Health Law Section 4201. -ORI/We 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. My/Our relationship to the deceased is as follows: Walter Frasier (Name of Deceased) DOS-1898-f(Rev.04/20) Page 1 of 3 V Authorization for Cremation and Disposition (Insert from the fist below) Number: 2 Description: Spouse 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 is acting on behalf of the deceased and who has executed a written statement pursuant to Public Health Law Section 4201(7). (Initial ALIfTHREE of the following) I --//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 prior to the execution of this Authorization Form. Failure to remove thes 1s prior to cremation may result in harm to the crematory and crematory personnel. orI/We affirm that instructions have been given to Wendy M. Bulich (Funeral Director Name) 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 Crematorium (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 con ;9or with the remains will be destroyed by the cremation process and cannot be retrieved after cremation. r . I/We hereby authorize Pine View Crematorium (Crematory Name) to cremate the remains of the deceased. (Initial OPTIONAL) Ilwe 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:Singleton Sullivan Potter Funeral Home Address: 407 Bay Road, Queensbury, NY 12804 Phone: (518) 793-4459 The cremated remains of deceased will be disposed of as follows: Burial Pine View Cemetery If for any reason the person named above does not take possession of the cremated remains, Pine View Crematorium is authorized to give possession of (Crematory Name) the remains to Singleton Sullivan Potter Funeral Home by delivery (Funeral Home Name) in person or by registered mail. Walter Frasier (Name of Deceased) DOS-1898-f(Rev.04/20) Page 2 of 3 Authorization for Cremation and Disposition (Initial the following) � ''l) I/We understand that if the remains are not claimed within 120 days of cremation, � Pine View Crematorium may dispose of the remains in (Name of Crematory) 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. -O .7 iAn urn is not yet purchased. I/We understand that if no urn is purchased or otherwise provided Pine View Crematorium will place the cremated remains in (Name of Crematory) a rigid temporary container for delivery. This Authorization Form was provided by Wendy M. Bulich was executed at (Funeral Director Name) Singleton Sullivan Potter Funeral Home (Funeral Home Name) 407 Bay 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 authorizes)the foregoing. Signed this 8th day of October ,20 21 . Linda A. Frasier Typed or Printed Name Signatu0 �r 35 Snowberry Road, Malta, NY 12020- ,� \-----_-- -- Address Typed or Printed Name Signature Address Typed or Printed Name Signature Address WITNESS: Wendy M. Bulich ) (Funeral Director Typed or Printed Name) (Funeral Director Sig ture) 10441 (Registration Number) Walter Frasier (Name of Deceased) DOS-1898-f(Rev.04/20) Page 3 of 3 Town of Queensbury Certification of Cremation � � Pine View Cemetery and Crematory This certifies that the remains of: Walter Frasier were cremated on October 12 20 21 at the Pine View (Month) (Day) Crematorium, Queensbury,New York, and these are the cremated remains of said body. Date of Death October 8 20 21 Age 81 (Month) (Day) Funeral Home Singleton Sullivan Potter Registered No. 855 (Authorized Signature) FRASIER NAME Walter Frasier Age: 81 Lot Owner: Marion H Frasier Lot# WAHTAWAH 1-121 s-3 3 Grave# 1 6 B Case: Urn Died: 1 0.8.2 1 Interred:1 0. 1 9.21 Funeral Home: Singleton Sullivan Potter Cemetery: Pine View