Morgan, Scott H Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: _(QF_ al.01.) SocTE p_t'.....(11LIIin?QE►JllitiN?l_._ RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY; . ......_.__._........._......__--�.I.�ZL..z.2.- Iz I6pn_
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
5 'f 14iC0
NAME;
_.._..__._- Sion ........M ERG AI CASE #
TYPE OF CONTAINER: o-(--kto__. ��-..� 41u -.....��z.KvE�_._.._ TZ�M u Syr
PLACE OF DEATH: (�(t.f �s�( II
ESTIMATED WEIGHT OF REMAINS 8, CONTAINER
PLACED IN HOLD:
PLACED IN REFRIGERATION: -.-. I 13sfri
DATE OF CREMATION: 1 tigi Z
TIME STARTED: -7 : 16V TIME COMPLETED:
PLACED IN RETORT: �_)0 MOVED: _....__-_._.._...__....__........__$._ZS- _A:'yin
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
1'E3itK Department of state
STATE OF ivisio O DIVlSION of frlEf�tET Es
. OPPORTUNITY. One Commerce Awe
�'�,I9_ Cemeteries ies 99 wdSMn9ton Avenue
Albany,NY 12231-0001
Telephone:I51e)474.6226
aOS goV
Authorization for Cremation and Disposition
i•
This Authorization Form must be completed and signed prior to delivery of remains for cremation.
Date:... ! \a.........S-1, !a` ---. Number., _ 9S
Crematory Name:_�p \�-ON U JJ��i.;� t„
Address: 12 .14Y �C. 15�. VAN ne: S\ �— �15 3:21\_......_.
i CREMATION IS AN IRREVERSIBLE o
AND FINAL PROCESS.
1 Cremation is carried out by placing the remains of the deceased and the container holding the remains into a cremation chamber where
I they are subjected to intense heat and flame The heat and flame will Incinerate and consume everything except bone and meta!,
I which are All that will be left after c►emallon_
•
1 Following cremation,the crematory will take reasonable efforts to remove all of the remains and other material from the cremation
chamber,but some minimal duet 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 reinabts 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 OE.THE CONTAINER a . ' . -- -__,-.0
The tremetory they only open the container tlotdktg the un-cremated human remains in halted 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. It
human remains are delivered in a container which is not suitable for cremation such as cereraonIal or rental casket,the
crematory will require that the remains be moved Into a suitable container before it accepts t e 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,
lOEHTJFIFATION OE DECEASED
Name of Deceased: (' 0-1-#7, , i -14-- - _ct i - Marital Status, it 'law 0 d
Last Known Address: I„'7 :0/1 C�U�kS S2 ' f t V i I .. 1 a_si 3-D•
i lace of Death: ��� _S^-:,t (ls t� �a o 1 - -�-
Sex• Q F Age:l{J 0 DOH: 3 A.4\e,3 Pate of Death: \\ a I.\ &yi.tecivight. ,_ Z° i b 6
Description of in which remains wit be delivered
SS
PERSON ill ctf1TROI.OF DISPOSITIQN •
(Pereon(s)in control of diSpoeflon,taffie ONE of(he•following) -
84
J I am/We are the designated agent of the deceased designated in a will or written instrument executed pursuant to Public
Health Law Section 4201
-OR-
slave have no knowledge that the deceased executed a written instrument pursuant to Public lieallh Law Section 4201 or a
will containing directions for the disposition of his or her remains and ewe ere the person(s)having priority under Public Health Law
Section 4201 and have me right to authorize cremation of the remains of the deceased. My/Our relationship to the deceased Is as
follows:
t
DOS-1888-f(Rev 08/15) Page 1 of 3
Authorization for Cremation and Disposition
(Insert from the lief below)
Number' Description: 'I -
I. A person designated in writing put-mint 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 persons)eighteen years of ape or older entitled to share in the estate and who isiere closest In relationship to the deceased;
a. A duly appointed fiduciary of the estate,
S. A dose friend or relative who has executed a written statement pursuant to Public Health taw Section 4201(7);
10, A chief fiscal officer of a county or a public administrator appointed pursuant to the Surrogate's Court Procedure Act,
tOe. Any ether person who is acting on behalf of the deceased and who has executed a written statement pursuant to Pubtrc Health
Law Section 4201(7)
(gig(A4,t THREE of the following)
IANe hereby affirm that the body of the deceased does not contain a battery,battery pack,power cell,radioactive imptani,
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.
UWe affirm that instructions have been given to.,,_ )_ es c _ ���r�,r� ---••
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. imsecuy we) Y
is not responsible for the removal of personal items from the container or from the remains of the deceasedec Personal Iterns left in the
container or with the remains will be destroyed by the cremation process and cannot be retrieved after cremation.
hWe hereby authorize 1 �, V <;,Az _,�� r roolwriwrowo
.. .
to cremate the remain*of the deceased.
Fit.DISPOSITION
The person authorized to receive the cremated remains of the deceased from the crematory is'
Name; C'_S 4� ri�y c. , \ •
t wu
- l 9�Phone;,) ' 7 f) I.1 J
The cremated remains of deceased will be disposed of as follows:
if for a,reason the person named above dose not take possession of the cremated remains,
id7 c C-..c-).. I< � - -.�----.- -w.� is authorized to give possession of
!aeroceyNdnsl ``
the remains to -> y'`J` . - -- by delivery
f4MM riser a.mei
in person or by registered mail
•=;:'4
DOS-1898-f(Rev 08/15) Pape 2 of 3
Authorization for Cremation and Disposition
(/real the faikeving)
. ci),1 Wye understand that ifthe remains ere notdalmed within 120 days of craMatinn,
v P \1 c r-;�-, .�Remo mew* . maydispose
,»c , c.:-� C: �r of the remains In
an irretrievable manner,such as by scattering
GRf.MATION CONTAINER/URN
(/chat ONE of the following)
An um to be used as a container for the cremated remains has been purchased from . .�
and is described as follows;
t/We understand that u the urn is too small to hold the entire aerated remains,an add Lionel right container may be used for delivery.
.An urn is not yet purchased Me understand that if no urn is purchased or othenMise provided
. .• .._ . . l piece the cremated remains in
(am.orCra )
e rigid temporary container for delivery 1_
This Authorization Form was provided by ,. ` ` tCi Vi 6bUYVN;I 1 was executed at
and is signed by the funeral director as witness to its arise utiun
IAMB have received a completed copy of this Authorisation Eons.
The person(s)Identified below ilstlare the personfa)In control of disposition,vitro by sigehig this Authorization Form,Multi)
to the accuracy and completeness of the Information contained in this Autirorirslion Form sad eutfwrise(s)the foregoing.
Signed this- j 5 day of[ .V-(AlAik .zc .
•r)pedorrif loeNars • - mre .. .�«. . ._`
Napaor+4tarNe.. gawk*
Maws - - - . . . .
WITNESS:
*Mai&IWO/irnetrowspedmaw " aeialifeawsgn�'
Paine arUuru. ay `/J\
0OS-1e88•f(Rev 08/15) Page 3•ot3•
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