Liberty, Dorothea G Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: ). y7/� RETURN TIME: %-gt/`S
DATE & TIME REMAINS ARRIVED AT CREMATORY: // //& - Zo2
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
II
NAME: :be)re.) /�.Qet_ L, `J��4 CASE # /0 , 1
TYPE OF CONTAINER:-Flo )ce f 4_4/2A) 6,1-V., I�CY"' < ��, �,$)e
PLACE OF DEATH: hi-LJgc Ti' ' - T'
1 7 9,.1d,era(jk , .' 7 / /28g3
ESTIMATED WEIGHT OF REMAINS & CONTAINER_ /30 A S
PLACED IN HOLD: /
PLACED IN REFRIGERATION:
DATE OF CREMATION: J4- a- aOcI
TIME STARTED: _,r- TIME COMPLETED: 9IL ^
PLACED IN RETORT: / MOVED: 1 / _ L� y
11
RETORT # IN WHICH REMAINS WERE CREMATED: 6 Qbcoer
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.
a
New York State
Division of Department OF CEMETERIES
RIES
tate
NEW YORK DIVISION OF CEMETERIES
STATE OF One Commerce Plaza
OPPORTUNITY_
PPONI1 Cemeteries 99 Washington Avenue
Ly 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.
' I
Date: f lI vQ Number. �� Ci
Crematory Name:Pine View Crematory
Address: 07 l 6l c kc r._ 2J Gs N'f I Cc Phone: 5 6-7 4/5 -f l 7 7
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 win Tikely be left behind. The crematory will separate incidentaland 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 am 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 endosed 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: D0 N Cr 1 ell- 6. I Marital Status: w I d"41
Last Known Address: U` S f2`1"-9 4/10r .5'll PIG'Co Sc it'./. /
Place of Death: E( ei-WI."000C cA.' . -re er.=d.Q A)7' f 7- P83 /G3
Sec D M 04 F Age: (717 DOB: G 3 a� I g a y Date of Death: //1 a g f v / Estimated Weight /3 0
Description of casket/container in which remains will be delivered.
e !1,'ioa..
PERSON IN CONTROL OF DISPOSITION f
(Person(s)in control of disposition,initial ONE of the followin
are ignated ag a deceased designated in a will or written instrument exea rbed pursuant b PUblir;— -
H 1 Law 4201.
_O
►' L IfWe have no knowiedge 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 Ave 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:
1,-O iQ.a_- G. A :4 r 7
Naos of
DOS-1898-f(Rev.08115) Page 1 of 3
Authorization for Cremation and Disposition
(Insert from the list below)
Number. . ) Description: SO ti l? ��r> 0 t-- d Ate 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).
(Initial ALL THREE of the following) r_
, __ir--IIWe hereby affirm that the body of the deceased loss not contain a battery,b 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 cremation may result in harm to the crematory and crematory personnel.
14 IMIe affirmthat instructions have been given to h1 a'AN ( "
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
((spy 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.
UWe hereby authorize
Pine View Crematory
(Crematory Woe)
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
Address:
1019 US Rt.9 PO Box 548,Schroon Lake,NY 12870 Phone:518 532-7177
The cremated remains of deceased will be disposed of as follows:
4-iurer° -- 5-1--f"v5 t7 Sr. r')Ip► 3 C)eA 1;7 No hlrictsc ,uy.
•
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
(cn
the remains to Edward L Kelly Funeral Home by delivery
(Funeral Horn Name)
in person or by registered mail. {^I
{)� b,2,--"ry
(Name of
DOS-1898-f(Rev.08/15) Page 2 of 3
Authorization for Cremation and Disposition
(Initial the following)
T /
i 1, Wile understand that if the remains are not claimed within 120 days of cremation,
Pine View Crematory
may dispose of the remains in
pone aoemeeot,)
an irretrievable manner,such as by scattering.
CREMATION CONTAINERNRN
(Initial ONE of the following)
Anm-Co u be u as a container e cremated remains as been d�r fell Fune ome
and is 4 'bed as follows:
WVe un erstand that if the urn is too small to hold the entire cremated remains,an additional rigid container may be used for delivery.
-OR��,''1�F An urn is not yet purchased. WVe understand that if no urn is purchased or otherwise provided
pioe-11 Zi 9 ens. e G44se"A Tory" will place the cremated remains in
(Name acreniefood
a rigid temporary container for delivery.
This Authorization Form was provided by C' ' it" ' 7
milt was executed at
Edward L Kelly Funeral Home .
(Funeral Horne Nome)
1019 US Rt 9,PO Box 548 Schroon Lake,NY 12870
FieeralHome Addiesx)
and is signed by the funeral director as witness to its execution.
Me have received a completed copy of this Authorization Form.
The person(s)identified below Islam 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(s)the foregoing.
Signed this ' day of tuoi2e,r, 4 — ,2042 -. , pj ,.1.72._
0-.7P.. -7-- - 7ci.rm.da.,L ,7 r,i-,z.
Fo-73-6r4 /42- Aib I-- -'4 /4 cis c,v / Aiii/ /2s...5-3-7
Address I
Typed or Printed Nome Signatute
Address
Typed orPrhrted Name
Address
WITNESS:
cAg" 'r elI i YL/i
(Funeral Dred&Typed or Printed Name) Ste)
//!my
oh4l/.ee. 6, ti ; ,
0Lr/
tame ofDeoesseap
DOS-1898-f(Rev.08/15) Page 3 of 3