Whitman, Susan A Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: /111-tiPZ
RETURN TIME: .. .
DATE & TIME REMAINS ARRIVED AT CREMATORY: 1;LiCittl NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
Met
NAME: 5V5.40 1%) mAisi
CASE tt
TYPE OF CONTAINER: ...
PLACE OF DEATH: ._ Ilf44
ESTIMATED WEIGHT OF REMAINS & CONTAINER NO 4)
PLACED IN HOLD:
PLACED IN REFRIGERATION: /0:PO siti
DATE OF CREMATION: JO_.111.V.
TIME STARTED: 1'6411 TIME COMPLETED:
PLACED IN RETORT: _._. g'OC)all MOVED: c'041/ zerri
RETORT 4 IN WHICH REMAINS WERE CREMATED: rV
10:704
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.
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y. s
New York State
erf—INEWYORK ' Division of Deportmentofsmte
STATE OF One
OF CEIIAETERIes
Plaz
OPPORTUNITY. • Commerce Ington e
Cemeteries 99 washlrgton Avenue
Albany,NY 12231-0001
Telephone:(Ste)474.6226
www.dosny.gov
Authorization for Cremation and Disposition
This Authorization Form must be completed and signed prior to delivery of remains for cremation.
10//5/2021
Date: Number: S31
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.
Fnllnwing rrsmation,the oromotory will take reasanable effollz to ICI lluve 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
Susan A.Whitman Married
Name of Deceased: Marital Status:
8846 NYS Rte.30,Blue Mountain Lake,NY 12812
Last Known Address:
Glens Falls Hospital,Glens Falls,NY 12801
Place of Death: J�
Sex: 0 M ® F Age:77 DOB: 6/18/1944 10/5/2021
Date of Death: Estimated Weight �Tt1
Description of casket/container in which remains will be delivered.
MacDonald Container; basic cardboard cremation container
PERSON IN CONTROL OF DISPOSITION
(Person(3)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.
-OR-
WVe 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:
SuSan wt'i•itnian
(Name d Damsel)
DOS-1898-f(Rev.04/20) Page 1 of 3
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Authorization for Cremation and Disposition
(Insert bogy the list below) husband
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;
6. 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).
((ygg(ALL THREE of the following)
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
these Items prior to orematlon may result in harm to the crematory and crematory personnel.
p��� Patricia Miter
ak. I/We affirm that instructions have been given to
(Funeral Drreeror Nome)
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.
(Crameraryhame)
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_ Ilwe hereby authorize Pine View Crematory
(Crsmerery Norm,
to cremate the remains of the deceased.
(Initial OPTIONAL)
Uwe 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:
8357 NYS Rte.30,Indian Lake,NY 12842 518-648-0011
Address: Phone:
The cremated remains of deceased wil be disposed of as follows
burial in Blue Mountain Lake Cemetery
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
(Cremator/Nam)
016 remains to Miller Funeral Home
by delivery
in person or by registered maltl u n A.Whitman
(Name of Demand)
DOS-1898-f(Rev.04/20) Page 2 of 3
(rieprnberron Nunefw
Susan A.Whitman
, rower,or Deceased)
DOS-18984(Rev,04/20) Page 3 of 3
10/05/2021 13:41 5186486227 JULIE PAGE 01/02
I� a
- • ■lie!
Authorization for Cremation and Disposition
(Initial the following)
IMIe understand that if the remains are not claimed within 120 days of cremation,
Pine View Crematory
may dispose of the remains in
Mane of C emstory)
an irretrievable manner,such as by scattering.
CREMATION CONTAINER/URN
(llritial 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.
-OR-
An urn is not yet purchased. lIWe understand that if no urn Is purchased or otherwise provided
Pin view Crematory
will place the cremated remains in
(None olc.emetory)
a rigid temporary container for delivery.
Patricia Miller
This Authorization Form was provided by was executed at
rowel Director Nome)
Miller Funeral Home
6357 NYS Rte.30,Indian Lake, NY 12842 (Funerwr+omeNn,nn)
(funeral Honk Addmi.)
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 Islam 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 authorbaa(s)the foregoing.
5 October 21
Signed this day of ,20
Joseph Whitman
W
TYPnd or Printed Nam?
pnekae
PO Box 33,Blue Mountain Lake, NY 12812
AddmI3 -•
iyp.d or nlea Naha Spnnrure
Addirrie
Typed orPdnta,Nemo Sipnnhire — -
WITNESS:
Patricia Miller \portututsout
(Furtive,Director Typed or Printed Naas) Winteol Director sonstuee)
12465
(Rep7etrevon Number)
Susan A.Whitman
••, !Nacre of bpcii uece
DOS-1898-f(Rev,04/20) Page 3 of 3