Cloran, Charles A (2) Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME:
ALMA,. .
__......_... ._........_...._._. RETURN TIME:
DATE _....------..—_---
& TIME REMAINS ARRIVED AT CREMATORY: I'
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERINGu•
REMAINS:
NAME: --- I� �FS_.__._.._G`DIA1J
...CASE # SZq
TYPE OF CONTAINER: M4I.Do
--_------ --_. 1----4t��1% fit« �A„rILO,at
PLACE OF DEATH: _- __ IS$ _.._I1p�l�___Pe‘et Sou
ESTIMATED WEIGHT OF REMAINS & CONTAINER_, . -_- - —_IQo._.
PLACED IN HOLD: _ J(;ic-
PLACED IN REFRIGERATION:
DATE OF CREMATION:
TIME STARTED: /(:7 p
--------------.._._..._----...._ TIME COMPLETED:
PLACED IN RETORT: _. it.3_°./111 _.. 1L; D
3Si ri rZ:sSfP I
RETORT U IN WHICH REMAINS WERE CREMATED: __ ..... l/6{/
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.
" ' NON York State
, Department of State
NEW YORK DIVISION CEMETERIES
STATE OF Division of One Commerce Plaza
OPPORTUNITY., Cemeteries 99 washingtor�Aver
Albany.NY 122310001
Telephone:($18)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.
9/30/2021 I g Z 1
Date: Number.
Crematory Name: Pine View Crematory
Quaker Rd.,Queensbury, NY 12804 518-745-4477
Address: + Phone:
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 arid 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 DECEASEt
Charles A.Clc)ran Marred
Name of Deceased: Marital Status:
198 Bluebird Rd.,South Glens Falls,NY 12803
Last Known Address:
residence I
Place of Death:
88 11/11/1932 9/29/2021 180
Sex: ElM 0 F Age: ,DOB: Date of Death: Estimated Weight:
Description of casket/container in which remains will be delivered.
MacDonald Container, Basic cardboard cremation 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 executed pursuant to Public
Health w Section 4201.
-OR- )
I/We have no knowledge that the deceased executed a written instrument pursuant to Public Health Law Section 4201 or a
wilrcon ming 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: I' Charles A. Cloran
I
1 (Name 0 Deceased)
DOS-1898-f(Rev. 04/20) Page 1 of 3
Authorization for Cremation and Disposition
(1 i is(,he following)
I/We understand that if the remains are not claimed within 120 days of cremation,
• View Crematory
may dispose of the remains in
(None of Cnrmetory,
an irretrievable manner, such as by scattenng.
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 ngid container may be used for delivery
-O
j An urn is not yet purchased. I/We understand that if no urn is purchased or otherwise provided
View Crematory
will place the cremated remains in
(Name of CraneMry)
a rigid temporary container for delivery.
Patricia Miller
This Authorization Form was provided by __was executed at
(Fume's!Ouecfw Name)
(Funeral/,bme Name)
6357 NYS Rte.30, Indian Lake, NY 12842
(Funeral Home Address)
and is signed by the funeral directories 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 ping this Authorization Form,attest(s)
to the accuracy and completenesl of the information contained in this Authorizatio F and authorize(s)the foregoing.
30 September 21
Signed this day of ,20
Elise Stubbs
Typal or PNrtd Nana Signature • __
PO Box CR 294,Hamilton,Bermuda CR BX
Address
Typed or Pnnrod Name ! &ona(ure
Alas
Typed or Printed Name Screams
..............
Adores,
WITNESS:
Patricia Miller
(FUMra!Dro cler Typed or Plated Name) (Fuse,*amclor shoe)
12465
Arpostrobar Member)
Charles A. Cloran
(Name of Deceased)
DOS-1898-f(Rev 04/20) 1'a"-ae of
Authorization for Cremation and Disposition
(Insert frog)the list below) daughter
Number. Description:
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 dosest 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).
(Initi L THREE 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
th items prior to cremation may result In harm to the crematory and crematory personnel.
Patricia Miller
f INVe affirm that instructions have been given to
(Funeral Director Nine)
regarding the removal of any personal property or other thing of value which any person signing below or any family member of the
Pine View Crematory
deceased wishes to preserve.
(craniology Name)
is not sponsible for the removal of personal items from the container or from the remains of the deceased. Personal items left in the
• • r or with the remains will be destroyed by the cremation process and cannot be retrieved after cremation.
Pine View Crematory
_,. I/We hereby authorize
(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 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:
Miller Funeral Home
Name:
6357 NYS Rte.30, Indian Lake, NY 12842 518-648-0011
Address: Phone:
The cremated remains of deceased will be disposed of as follows:
returned to family
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 Miller Funeral Home by delivery
(Funeral Honisaarles A.Cloran
in person or by registered mail.
f mmo of C1 caaase'Y)
DOS-1898-f(Rev.04/20) Page 2 of 3