Renz, Jo Ann • TO T1N OF QUEENSBURT
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
�" Funeral Director 11F ICItr1e(Z.
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Time Cremation Started IZ , JO Al
Time Cremation Completed 2=WO$h
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NYS Department of State
AutIxrization for Cremation and Disposition Division of Cemeteries
One Commerce Plaza,99 Washington Avenue
Albany,NY 12231
(518)474-6226
www.dos.state.ny.us
This Authorization Form must be completed and signed prior to delivery of remains for cremation.
Date: Feb. 28, 2010 Number: 110
Crematory Name: Pine View Cemetery and Crematorium
Address: 21 Quaker Road Queensbury, New York 12804 Phone: 518-745-4477
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 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 crematory property. If human remains are delivered in a container which is not suitable for cremation
such as a 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: Jo Ann Renz Marital Status: Married
Last Known Address: 526 Gansevoort Road Fort Edward, New York 12828
Place of Death: Glens Falls Hospital
Sex: ❑M ❑x F Age: 61 DOB: Sept. 22, 1948 Date of Death: Feb. 28, 2010 Estimated Weight: 150 lbs.
Description of casket/container in which remains will be delivered:
(Alternative Container) New England Cremation Supply Company, Plywood Corrugated Cardboard Container.
PERSON IN CONTROL OF DISPOSITION
(Person(s in control of disposition, initial ONE of the following)
41,
AWL 'I am/We are the designated agent of the deceased designated in a will or written instrument executed
pursuan 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 will containing directions for the disposition of his or her remains and (continued next page)
Jo Ann Renz
DOS-1898-f-I (Rev.01/10) Name of Deceased Page 1 of 3
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I am/wie 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:
(Insert from the list below)
Number: 2 Description: The surviving spouse
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 §4201(7);
10. A chief fiscal officer of a county or a public administrator appointed pursuant to the Surrogate'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 §4201(7).
(Initial ALL THREE Of )
azr I/We 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 these items prior to cremation may result in harm to the crematory and
crematory personnel.
A`tb\ I/We hereby affirm that instructions have been given to (funeral director name) Claire C. Konopka
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. (crematory name) Pine View Cemetery and Crematorium is not
responsible for 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.
0A \ 1/We hereby authorize (crematory name) Pine View Cemetery and Crematorium 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: Claire C. Konopka
Address: 136 Main St. South Glens Falls, New York 12803 Phone: 518-745-8116
The cremated remains of deceased will be disposed of as follows:
Yet to be decided.
If for any reason the person named above does not take possession of the cremated remains,
(crematory name) Pine View Cemetery and Crematorium is authorized to give possession of the remains to
(funeral home name) M. B. Kilmer Funeral Home by delivery in person or by registered mail.
Jo Ann Renz
DOS-1898-f-I (Rev.01/10) Name of Deceased Page 2 of 3
ilriitial the following)
I/We understand that if the remains are not claimed within 120 days of cremation,
(crematory name) Pine View Cemetery and Crematorium may dispose of the remains in an irretrievable manner,
such as by scattering.
CREMATION CONTAINER/URN
(Ini 'a O E of the following)
An urn to be used as a container for the cremated remains has been purchased from
►ry-N . 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.
-OR-
An urn has not yet been purchased. I/We understand that if no urn is purchased or otherwise provided
(crematory name) Pine View Cemetery and Crematorium will place the cremated remains in a rigid temporary
container for delivery.
This Authorization Form was provided by (funeral director name) Claire C. Konopka
was executed at (funeral home name) M. B. Kilmer Funeral Home
(funeral home address) 136 Main St. South Glens Falls, New York 12803 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.
Si his 28th day of Feb. , 20 10
Typed or Printed N m Signature
Address I Q
Typed or Printed(Jame Sig ure
11 SC ssa PS 6 164, P1i( ld$ )
Address
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Typed or Pri ted Name Sig ure
19 C=c s+ CO- S . G LQ AS \ I Is t / e 3
Address
WITNESS:
Claire C. Konopka C_ ��.�
Funeral Director Typed or Printed Name Funeral Director Signature
01970
Registration Number
Jo Ann Renz
DOS-1898-f-I (Rev.01/10) Name of Deceased Page 3 of 3