D'Andrade, John P (2) Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: 14"41 • ------- • .. ... _ RETURN TIME: ....
DATE & TIME REMAINS ARRIVED AT CREMATORY: Wi(t/ 2 'coph NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
Obk13 ..
NAME: _. CASE II S3Z
.. ..
TYPE OF CONTAINER: rt 6.41:44:.. &reit bld
-------------
PLACEOFATH. VP
ESTIMATED WEIGHT OF REMAINS 8. CONTAINER iq.0_14# _. 8 Gip .......
PLACED IN HOLD:
PLACED IN REFRIGERATION: ________.. :)1/ ft)
DATE OF CREMATION: Le:2742-1202
• ia
TIME STARTED: 7 _ TIME COMPLETED: .
05)..PLACED IN RETORT: . . MOVED: OPr!'7 q/7
RETORT tt 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
NEW PORK Department of State
off— Division of DIVISION OF CEMETERIES
STATE OF One Commerce Plaza
lO 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: 1 o l 1 I LI Number. $3 L
Crematory Name:Pine View Crematory
Address: Zl Q✓kVt t. edvr( ( J 3 3 A ra, Note Phone: (510 7I ` 17)
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 ail 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 win 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 (� f
Name of Deceased: X0'lin' P- D / a r-r� ci Marital Status: S/VQ te.
Last Known Address: 3 Fc o `il l/�►- yA v- ._ 5cii i-0.0 ✓ r. k''� I37.
Place of Death: V L e arrj �/ /S W(yA /J/ . (Zcj Dl
Serc IM ❑F Age: (p Af DOS:06 by i/r.S 7 Date of Death: Q q la to/9-0 a) Estimated Weight/?6
Description of casket/container in which remains willw� be delivered.
rift-k )c t D^� arl�{ 1 I t�1�? l;�'i1('4/0 e —
PERSON IN CONTROL OF DISPOSITION
(Person(s)in control of disposition,initial ONE of the following)
a the desjg a ag the d seal designated in
Heal
-OR-
lIWe 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:
•-��1�it) f Q A t A(Nam of
DOS-1898-f(Rev.08115) Page 1 of 3
Authorization for Cremation and Disposition
(Insert from the list below)
Number: .. --Description: cJ f 61►?t 7 ►f-" Oey." r Y —
1. A person designated in writing pursuant to Public Health Law Section 4201(3);
2. The surviving spouse;
2a. The surviving domestic partner,
3. My 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. My person(s)eighteen years of age or older entitled to share in the estate and who islare 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).
(In ,al ALL THREE of the following) ' .
0 I WVe hereby affirm that the body of the deceased does not contain/a batte .battery pack,powercell,radioactive implant,
orradioactive device and that any such materials were removed prior to the execution of this Authorization Form. Failure to remove
items prior to cremation may result in harm to the crematory and crematory personnel.
-12
;______
I/We affirm that instructions have been given to ;It;A Kc-iiiiii
(farbrs�Qbeclbr
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
(pemetory Nye)
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.
IIWe hereby authorize Pine View Crematory
&#:-- (Gemology 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:51t3.532 7177
The cremated remains of deceased will be disposed of as follows:
R.Ct 0 -FINKULI
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
the remains to Edward L Kelly Funeral Home by delivery
(Funeral Home
in person or by registered mail. p k (�
v R 01 A XJ C]t^A(1-e___
(Neese of Deceased)
DOS-1898-f(Rev.08/15) Page 2 of 3
Authorization for Cremation and Disposition
l,'':_ the following)
if1 1/We understand that Witte remains are not claimed within 120 days of cremation,
Pine View Crematory
may dispose of the remains in
Name or r)
an irretrievable manner,such as by scattering.
CREMATION CONTAINER/URN
(Initial ONE of the following)
mi. • be used a-amain r th ma ad"Mr-reinsh rr based
Ad ally Funeral Home
1/We understand that if the um kW)sma hold 're crematedremait‘,..Initional rigid container may be for delivery.
-O--
14, An urn is not yet purchased. VWe understand that if no urn is purchased or otherwise provided
e . Pr e c1J k will place the cremated remains in
Name a
a rigid temporary container for delivery.
This Authorization Form was provided by (' 1T A-� J _ k—` / was executed at
(Fussed Director Nom)
Edward L Kelly Funeral Home
FuneralNano
1019 US Rt.9, PO Box 548 Schroon Lake,NY 12870 r ,ome r
(Fumed Home Address)
and is signed by the funeral director as witness to its execution.
INVe have received a completed copy of this Authorization Form_
The person(s)identified below islare the persons)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(*)the foregoing.
Signed this S% day of ( l cat e'" 20 g/
1.7
Address
Typed os-Printed Name
Address
Typed orPdalsd Name SWAN,
Adams
WITNESS:
(Funeral •4.,ryper I or Fri re) SiOnattmdl-' -164
4v,, (0- y
Xoh „) P 60 11 nr4i-nd'4_,
plain ofDece s.dp
DOS-1898-f(Rev.08/15) Page 3 of 3