Trapper, Richard A Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12604
(518) 745-4477 or (518) 745-4476
FUNERAL HOME:
_ RETURN TIME: NOf/j�
BATE & TIME REMAINS ARRIVED AT CREMATORY: -
NAME OF FUNERAL DIRECTOR OR REGRISTERED
RESIDENT DGLIVCRINC, REMAINS: •
TYPE OF CONTAINER: . .
PLACE OF DEATH: 2
.__ y ,iJ,� uc y of
ESTIMATED WEIGHT or REMAINS & CONTAINER 770
PLACED IN HOLD: ----
PLACED IN REFRIGERATION:
DATE OF CREMATION: I - _
TIMESTARTED: _.._-_-_.__.._.....__.__.---`•-_.__.-__..----_-___
TIME COMPLETED: �D :e��
PLACED IN RETORT: _
—._......._. .- ... _—.._ _MOVED: . �s
/V ern
RETORT 7/ IN WHICH REMAINS WERE CREMATED.
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THANAN -'-
FROM TIME OF ACCEPTED DELIVERY: -- HOURS
NOTE; THE CREMATION LOG SHALL RE RETAINED IN THE PERMANENT FILE OF THE CREMATORY
.
New York State
f—C-IN EW PORK Department of State
Division of DIVISION OF CEMETERIES
STATE OF One Commerce Plaza
OPPORTUNITY.. Cemeteries 99 Washington Avenue
Albany,NY 12231-0001
Telephone:(518)4746226
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: 10/2 i 1 t4 Number g
Crematory Name:Pine View Crematory
Address: Z t Q AWOL gm") d(AtN s8 JVb (Z901 Phone: (51g)7111-
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 Jeff behind. The crematory wtit separate bcidented 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 drcumstances,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: 'i i c t p rd A . ►^A Marital Status: /11, ri'-c.E‘
Last Known Address: 'IS //i j/9 v lc)/1 / 0/s/ _%e-C _ •r // ,u y' / 7
Place of Death: 21 5/.0//,'u a u w ni O/"S%e d ih'11e. fry 047-5-'7
Sex de50.4 ❑F Age: 76 DOB: OS/4 5/J?4, S Date of Death: /1/ 1 y/2o A/ Estimated Weight O
Description of casket/container in which remains will be delivered.
Flat-t vc-g- tM V eanwiee,- �v� A iii
PERSON iN CONTROL OF DISPOSITION
(Pe►son(s)in control of deposition,initial ONE of the Mowing)
I a re lute desi�g 1sfi�ng f the in a vx ent
Heal 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
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:
Frr,kird A - MI eieek:
(Yews or
DOS-1898-f(Rev.08/15) Page i of 3
Authorization for Cremation and Disposition
(Insert from the fist below)
Number: a. Description: Sur v(u/Mli fo0SR-
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. Any 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
10a. My other person who is acting on behalf of the deceased and who has.executed a written statement pursuantte Public Health
Law Section 4201(7).
(Initial THREE of the following)
IMIe hereby affirm that the body of the deceased does not contain a ,battery pads 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.AZ
`(17
IItNe affirm that instructions have been given to 4/o- �`regarding the removal of any personal property or other thing of value which any person signing below or any fern' of the
deceased wishes to preserve. amine Yew Crematory
(C+erary Mama)
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 o with the remains will be destroyed by the cremation process and cannot be retrieved after cremation.
Uwe hereby authorize Pine View Crematory
( aroywmel
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:
epi e.Tur-N e-c TG `�i-er4,s., ri- r
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
cciemafay
the remains to Edward L Kelly Funeral Home by delivery
(Funeral Home Name)
in person or by registered mail. , Q
fl��c 4 rci A, J ra�otise(tea
DOS-1898-f(Rev.08(15) Page 2 of 3
Authorization for Cremation and Disposition •
�y�JOWIng)
n I/We understand that if the remains are not claimed wIthin 120 days of cremation,
Pine View Crematory
may dispose of the remains in
(Nagle aaematoy)
an irretrievable manner,such as by scattering.
CREMATION CONTAINER/URN
(Initial ONE of the following)
• ••m to be as a •• r puma Edwa • Kelly F *-1 Ho
for the cram-i
and is •escrib=• as foil,#-: 4 .4r
INUe understand th- e urn is too small to hold the entire cremated remains,an additional rigid container may be used for•elivery.
-OR- /
An urn is not yet purchased. llWe understand that if no urn is purchased or otherwise provided
RN Vt ego
61—e441, loiy will place the cremated remains in
(Name of O,matci,)
a rigid temporary container for delivery. —Alhis Authorization Form was provided by l ('t rU a r'e—/ was executed at
rRmeretDfredorA�med
Edward L Kelly Funeral Home
Funeral Home
1019 US RL 9, PO Sox 548 Schroon Lake,NY 12870 Name)
(fiumd Home Address)
and is signed by the funeral director as witness to its execution.
UWe 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 Anth Form and authorizes)the foregoing.
Signed this )..{�-�d�ay of ('G`a A e r .20 y _____7____,
�(- ` 11 / t
7ypedorAfntedName eAd (4SU(Ij AP t00%i e)/nr sTe 0.44- 7--S7
Typed or Prated Name
Address
Typed or Pdrdad Name Signahre
Address
WITNESS:
i_l 0 4 it) ir• Wellit. gro ' ° 3 7 --4
(Funeral Tppgl arPmMid,larae)OG //C/J
I c:4A rd /• -1---r a,peer
(Namea0ecsas«q
DOS-1898-f(Rev.08115) Page 3 of 3