Lombardi, Anthony A Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: 1 .0•S RETURN TIME: HOPE
DATE & TIME REMAINS ARRIVED AT CREMATORY: 1(I2317,A ri;`1ce't1
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
i3oB ,3,i3-,,Eet
NAME: ANji4D(J1 ibe40IEPL CASE # 11
TYPE OF CONTAINER: ����A�,/j' - (ovr l 404 ( it-
PLACE OF DEATH: iCO IbLI$. 5644 $ . itue(0w4-i 171. O36(, -MR
ESTIMATED WEIGHT OF REMAINS & CONTAINER 23a /,4 3Sf(d
PLACED IN HOLD: (Z:to en j
PLACED IN REFRIGERATION:
DATE OF CREMATION: /1-?7- Ze4 /
TIME STARTED: 73 .-+ TIME COMPLETED: //
PLACED IN RETORT: Tee,' MOVED: � `� / - ',rY✓
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.
New York State
Nri—IEWYORK Division of DepartmentTE ES
STATE OF DIVISION OFF CEMETERIES
RIES
OPPORTUNITY_ One Commerce Plaza
Cemeteries 99 Washington Avenue
Albany,NY 122310001
Telephone(518)474-6226
www dos nygov
Authorization for Cremation and Disposition
This Authorization Form must be completed and signed prior to delivery of remains for cremation.
Date NI()Lk m.b 0,1 ? , c�-c`a t Number y q
Crematory Name l',t1 v 1 e L. j C i t r Cx._.1 , l ...43
Address ��,).z., I- ti___ ke t-tsbt•i t.1. l Nty I Z 6 1._i`-i Phone _7 1?- -t — LI �(i
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.
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
container or the transfer or removal of remains will be conducted before a witness and will be done in privacy, with dignity and res
IDENTIFICATION OF DECEASED m • �2r�D j
1
Name of Deceased
Yl�-�'lCi(1 !� t� • �L t'71�k�('c�..-i Marital Status. ' ="—••'
Last Known Address: ( 1(0`i ST r i h NA_ OL& 7., . N.\/ ( 1 :3(cC^
``�� � A i r, 2 C
Place of Death Lj�t v1S �t: .tit��r� t (� / 7�O) �4 1�'` V Tr1SI t-.t oc..�r �'i , (ZZ$
Sex- IA M ❑ F Age: 5 DOB: )(1 10 I It) 1- c Date of Death t I - 1(s - Z(YL I Estimated Weight 2 30 lit
Description of casket/con l iner in which remains will be delivered
l')1 D1A IBC{ L l)1 vnai i L fit`' Cl a t i ►u_i-- / llcxi'A GASI 1
PERSON IN CONTROL OF DISPOSITION
(Person(s)in control of disposition, ,,t ,,• ,4,
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-
._ I/We have no knowledge that the deceased executed a written instrument pursuant to Public Health Law Section 4201 or a
l 1 ontaining directions for the disposition of his or her remains and I/we are the person(s)having priority under Public Health Law
ction 4201 and have the right to authorize cremation of the remains of the deceased My/Our relationship to the deceased is as
follows
AY\1-1'/\j A y P . tAtVik x1i' 1
(Name of Deceased)
DOS-1898-f(Rev 08/15) Page 1 of 3
Authorization for Cremation and Disposition
(Insert from the list below)
Number�. Description: ..)t Ir V 1✓1 YJj `]OCy.,t.)j h.r-
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 Surrogates 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)
(Init.; THREE of the following)
'"` ..fir ", I/We hereby affirm that the body of the deceased does not contain a battery, battery pack, power cell, radioactive implant,
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.
I/We affirm that instructions have been given to_ ,7:).tt C W 4 A Pt-, LC)
(Funeral Director Name)
r garding the removal of any personal property or other thing of value which any person signing below or any family member of the
1 ,
deceased wishes to preserve � ; n e U i �L� �_�e r-)"1C...h)
(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
container or with the remains will be destroyed by the cremation process and cannot be retrieved after cremation
IIWe hereby authorize ti(1 e V I L,. C f N Y}�� nJ
r _
41/0
(Crematory 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: RC_ C., r"l �Q.e.r.)_Yl �r' ✓L.�F l rc..;►°Y-..z___
Address. ;7.-_') Et-,-t 1L•fQ. ).t :.SZ t i'l S 0 t- ..tt\-1 Phone S Z - H I L
The cremated remains of deceased will be disposed of as follows (2 ')L('
--c b k Ce4-v r r 1 10 Ayl Yam-fi _ 1.-mot-v r-c.9) i
If for any reason the person named above does not take possession of the cremated remains,
euv, ) i, cL, C_(e. rY\c )
is authorized to give possession of
Crematory Name) _
the remains to CA_r1 Dk-rl n L-1 5k�4,-_.k v c_. -f-- 1 by delivery
(Funeral Home Name)
in person or by registered mail
(Name of Deceased)
DOS-1898-f(Rev 08/15) Page 2 of 3
Authorization for Cremation and Disposition
(,iitia the following)
tds /We understand that if the remains are not claimed within 120 days of cremation,
may dispose of the remains in
'Name or 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
•' /
An urn is not yet purchased INVe understand that if no urn is purchased or otherwise provided
r I Y L)I k L•D Cr will place the cremated remains in
(Name of Crematory)
a rigid temporary container for delivery
This Authorization Form was
provided
i
by— �� �� t was executed at
(Funeral Director Name)
(1 ( ra-Home Name --`-----
(Fune41 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 authorize(s)the foregoing.
Lit 4Aiogorloftr
4. L v ►;amoV
iVO au6 Cresc-ev14 Zi ale r'Uc(J( li / 1/36
Typed or Panted Name Signature
Address � V�42 V••ti Q
yPr 1 't ma's
41:
Typed or Panted Name Signature •__,� WOhlMt1J�+P)
���""�"
Address
WITNESS: }c " -s -- - 4.4>•••• PutorN./..°�`��
mac.642 of C. SI-�e�+34, F.e- -t Dr�cca-d� '��N ao NN�'`�``�
(F ) `-1-)1 LL,,%.4 "f t r\�' I (EQenrat nr Gnnatym)
t C t`l r
(qeg cr�ynpp AN•mbe!
R'y1 \\� C�.CI) 1� "'",Name Deceased) l.r IyY�
IAU
DOS-1898-f(Rev 08/15) Page 3 of 3