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Wells, Peggy Pine View Cemetery & Crematorium Quaker Road Queensbury, NY 12804 (518) 745-4477 or (518) 745-4476 FUNERAL HOME: _Mt/6r- RETURN TIME: DATE & TIME REMAINS ARRIVED AT CREMATORY: _ /V A-- NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS: NAME: VLIA A)C1L5 CASE # __I fie_ TYPE OF CONTAINER: _ PLACE OF DEATH: aed,5 it5 1-119f,'4ziA / 10 I 4-r ito,i 5 ESTIMATED WEIGHT OF REMAINS & CONTAINER _7J 165 /613(4) PLACED IN HOLD: PLACED IN REFRIGERATION: Lft DATE OF CREMATION: _ 44-_27-Z0Z1 TIME STARTED: 143-'2, TIME COMPLETED: f"-V-- - PLACED IN RETORT: MOVED: RETORT it 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. 01/24/2006 11:43 5187932957 TOM BURGESS PAGE 04/09 Authorization for Cremation and Disposition (Insert from 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 snare in the estate and vino Is/are closest In relationship to the deceased; 6. 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'a Cuur(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). add ALL THREE of the following) (L� I/We hereby am►m treat the body of the deceased dues nut fx,ntaln a battery,battery pack,power veil,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. Patricia Miller c Me affirm that instructions have been given to (Fersrd Deed&Name) 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. (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. Ilwe hereby authorize Pine View Crematory (Crematory Name) to cremate the remains of the deceased. (Initial OPTIONAL.) l/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: Millar Funeral Home Name: 8357 NYS Rte.30.Indian Lake,NY 12842 518-648-0011 Addrese: Phone' The cremated remains of deceased will be disposed of as follows: returned to family If for any mason the person named above does not take possession of the cremated remains. Pine View Crematory is authorized to give possession of (*mew Name) the remains to Miller Funeral Home by delivery (Frr„armrrarr1Swg1Y Wells in person or by registered mail. �1 (Name of Deemed) DOS-1898-f(Rev.04/20) Page 2 of 3 01/24/2006 11:43 5187932957 TOM BURGESS PAGE 03/09 New York Stow Department of State NEWYORK Division of DIVISION OF CEMETERIES STATE OF One Commerce I'lozo OPPORTUNITY. Cemeteries 99 Washington Wton Avenue 111L�' Albany,NY 12ZAvenu 1 Telephone:(518)474.627A www.dos.ny.gov Authorization for Cremation and Disposition This Authodzatlon Form must be completed and signed prior to delivery of remains for cremation. 12/23121 � ) Date: Number; Crematory Name: Pine View Crematory Quaker Rd.,Queensbury,NY 12804 618-746-4477 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 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 propeAy. V 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. JPENTIFICATION OF DECEASED Widow Peggy Wells Name of Deceased: Marital Status: 6218 NYS Rte.30,Indian Lake,NY 12842 Last Known Address! Glens Falls Hospital,Glens Fails,NY 12801 Place of Death: 82 7/19/1939 12/21/21 Estimated Weight: 1 G Ihs Sex: ©M E3 F Age: DOB: r1 Date of Death: Description of casket/container in which remains will be delivered. PERSON IN CONTROL OF DISPOSITJON (Person(s)in control of disposition,initial ONE of the following) I arn/We are the designated agent of the deceased designated in a will or written instrument executed pursuant to Public Health Law Section 4201. -OR- Pbb/ 11We 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 1/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/Out relationship to the deceased Is as follows: Peggy Wells porno of oeceeeeo) DOS-1898-f(Rev.04/20) Page 1 of 3 01/25/2006 11:45 5187932957 TOM BURGESS PAGE 02/02 Authorization for Cremation and Disposition flnitiat??tthe following) IIWe understand that if the remains are not claimed within 120 days of cremation. Pine View Crematory may dispose of the remains In mime acrbnrotoeY) an Irretrievable manner,SuCh as by scattering, CREMATION.CONTAINER/URN (/oltla(ONE of the(ollowing) An urn to be used as a container for the cremated remains has been purchased from and is described as follows: I/We urtdursland that if the um 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. IIWe understand that if no urn is purchased or otherwise provided -Pie View Crematory will place the cremated remains in Worn of Asmslo.y) a rigid temporary container for delivery. Patricia Miller This Authorization Form was provided by was executed at (Funeral D*ecrbr Nam) Miller Funeral Home 8337 NYC Rte.30,Indian Lake,NY 12842 Mantel Nome Nsms) 1Funani NomsAddsss) and is signed by the funeral director as witness to its execution. DO I/We have received a completed copy of this Authorization corm. The persons)Identified below Is/are the persons)In control of disposition,who by signing this Authorization Form,attast(s) to the accuracy and completeness of the information contained In this Authorization Form and authorizes)the foregoing. 23 December 21 Signed this day of ,20 Barbara Burgess tithrMA.2. , Wye Hidden Hills Or.,Clueensbury.NY 12804 s�� /44'.* Addass Time or Pnnrad Nana OrPefuril MMus 7ypetl or PAripd Nona Address VATNESS: Patrice Miller ""Waal OLoolor Type PrMkd NOM) (Po Aor 12465 Peggy Wells -Ofosawsse DOS-1898-f(Rev.04120) Page 2 of 3