Noxon, Lillian L Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: RETURN TIME: _ ...
DATE & TIME REMAINS ARRIVED AT CREMATORY; I/Ili Zr1:56f11
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
SO 1-10 V et LI
_ .
NAME: CASE #
TYPE OF CONTAINER: P# Eit ,,4 Fakv(iloff( Ask 444...
• -
PLACE OF DEATH: 131liser4:%.44 , S."4 kss 1716
ESTIMATED WEIGHT OF REMAINS & CONTAINER
PLACED IN HOLD: _________ • _ .
PLACED IN REFRIGERATION:
DATE OF CREMATION: _ Uri [72
TIME STARTED: 11;i1. TIME COMPLETED: _ Cfri
PLACED IN RETORT: )2/Dq MOVED: /2:LiClqf KM
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
NE1NYORK Divis10110f Department ofState
TX-STATE OF DIVISION OF CEMETERIES
One Commerce Plaza
LOPPORTUNITY..
Cemeteries 99 Washington Avenue
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.
Date: I /A t I-It Number. 3
Crematory Name:Pine View Crematory
Address: 11. Qv kaci, eo ) Q edP4 / Phone: ( es))K54"I it
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 w)A 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 D/ECEkS /
Name of Deceased: j / Iq A "- . ✓J1 C X C/L) Marital Status: /()i.0 o t?
Last Known Address: .3/ n;,j/1 r-A cite- �.�r L) ' 1'16_ /us/. /d L 76)
Place of Death: We-Alt( 1../o..a/,y4 e41-e, ✓ � / 3i X aw rQP4 Sr � �.� giw v my- io
[
Sex: ❑M F Age: 103 DOB: C)q/13// /`8 Date of Death: O l /0- 2 Estimated Weight /OC)
Description of casket/container in which remains will be delivered.
Neu: �uSiAi�d ehhCr-►ArioN e,u r. ,4,4 I, utc( C:►- cT iitI �rUt- ' ( )A ` tom
PERSON IN CONTROL OF DISPOSITION
(Person(s)in control of disposition,initial ONE of the following)
a deal e d ign • written i pursuant to Public
Health L S on 4201.
nn11-QR
Lai ( IiWe 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(e)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:
11144 L • Nov' to
AV eme dDeo
DOS-1898-f(Rev.08/15) Page 1 of 3
Authorization for Cremation and Disposition
(insert from the list below) Sox)
v
Number. Description: ,,'vV it 01'i17
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
S. 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 dust in relationship to the deceased;
8. A duly appointed fiduciary of the estate;
9. A close fiend 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 Sum3gate'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).
ALL THREE of the following)
:7_,.....__
UWe 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
Items prior to cremation may result in harm to the crematory and crematory personnel.
x /� UWe affirm that instructions have been given to VD14d T T/1M
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
amatory 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
liner or with the remains will be destroyed by the cremation process and cannot be retrieved after cremation.
r/' UWe hereby authorize Pine View Crematory
Rena«y+aml
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,NV 12870 Phone:518-532 7177
The cremated remains of deceased will be disposed of as follows:
T+11 re,-i-e i l ,.., i-in i Iy (cc'T 6..l
S cli rceu A ra ea.... �`'vrl an JrU I 13- e.>,-,4'-771/
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
rceemereseer
the remains inEdward L Kelly Funeral Home
by delivery
(Funeral How•Name)
in person or by registered mail.
A ; 1140 , _ /Svxort/
IlVarne of
DOS-168&f(Rev.08115) Page 2 of 3
-a
Authorization for Cremation and Disposition
(I y 8I the following)
INVe understand that if the remains are not claimed within 120 days of cremation,
ire View Crematory may dispose of the remains in
(Name of Cemetery)
an irretrievable manner,such as by scattering.
CREMATION CONTAINER/URN
(Initial ONE of the following)
try-6VA An urn to be used asa container for the cremated remains has been purchased from Edward L Kelly Funeral Home
and is described as follows: 6 t e-'I`-) Al A I- o tJ
INVe 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 urlt i et purr . INVe understand that if n is purchased 'se provided
will place the crema�d`remains in
(Name of Crematory)
a rigid temporary container for delivery. ��
This Authorization Form was provided by ,�+ v 41) / was executed at
(Funeral Director Name)
Edward L Kelly Funeral Home
1019 US Rt.9,PO Box 548 Schroon Lake, NY 12870 (Funeral Home Name)
(Foneml Nome Address)
and is signed by the funeral director as witness to its execution.
INVe have received a completed copy of this Authorization Form.
The person(s)Identified below islare 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.
Signed this I day of A ti T 7 ,20
f,u( n.t Gil
�C �0
Typed or Flailed Name
ay A57 Kidel- Di- Lvze4, % 2 8"y6,
Typed or Pruned Name Signal m
Arbrose
Typal or Primal Name Skrialine
MOWS
WITNESS:
(Funeral r ar�yaaa) / (Funeral - )
(Regisuaaon Mnnbeq � I l(
/L)o)10 A)
(N�of
DOS-1898-f(Rev.08/15) Page 3 of 3