Bynes, Blanche M LO'WW OF Q5JyB1.1
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director I,
I Cyr �.. �hh�
Name I
� Case #
Date of Cremation ‘,„( LI 76) b
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Timype oe CrfeComationtinn Started
Time Cremation Completed trO0 ���►-1
Container l�.cl YJc;:r�� CRI,I i1 p ,�;t
Remarks :
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office: (518)745-4476,Crematorium: (518)745-4477
Authorization to Cremate
The undersigned requests and authorizes Pine View Crematorium,In accordance with and subject to its Rules and Regulations to
cremate the of
--remains f
ukc
(Name) 4 (Sex)
4 VuIlit Vikr4;1)glum J-dii401 (zEo3
(Street) (City) (� (State) (Zip Code)
who //on
2g day of i�Y.Ydr 20 (6
at l.014.os u'f x.Q I S
(Place) (Address)
Name and address of nearest living relative or name of a cremation:
ACItioiI cclac L 20 oyzea. ,lJ . Dlzralct- , 'I
• (Name) (Address)
Relationship to the
Name of Funeral Home . '(WC CL. ( ' La L I 1 _
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or(has no)pacemaker,defibrillator,battery,battery pads,power
cell,radioactive implant or radioactive device in his or her body.(Circle One)
I certify that I have full power and authorization to arrange for the cremation of the remains and to direct the disposition of the
cremated remains,that any personal possessions have either been removed or may be destroyed,and agree to protect,defend and
save harmless Pine View Crematorium from any and all daims and demands for loss or damages which may be made against them
by reason of or connected with the cremation of said remains as directed,whether such claims or demands are or are not wholly
worViess,false or fraudulent
0 •
(witness) (Address)
(Signature Address o e or Legal Representative)
Signed on this date:
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify: I-621MA T 0 �-f' it i r V`�
If pulverization of cremated remains is requested,check
•
Revision:April 18,2007
rl
Authorization for Cremation and Disposition NYS Department of State
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:A ,Gt () 2 .O I p Number:
Crematory Name: tikQ ta---
---)
Address: Qt.trattn I2SZI. 6,
Phone:? j- -
71
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: Pa4 C(,A C 11 i? WA. r , &QJ Marital Status: 10
Last Known Address: l Noul j, ( , .qp(j ,QJLi p l 12gC3
Place of Death:ple.Q.uAL f
Sex: ❑M RF Age:" l—( DOB: 1-14 )Q3 2 Date of Death:t 21 Z (ZA/o Estimated Weight:
Description of casket/container in which remains will be delivered:
C8).40 (4 aid a_a e.t/
PERSON IN CONTROL OF DISPOSITION
(Person(s)in control of disposition, initial ONE of the following)
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-
I/We have no knowledge that the deceased executed a written instrument pursuant to Public Health Law
sec ion 4201 or a will containing directions for the disposition of his or her remains and (Continued next page)
NttAkdAg- IAA ri61 vtita.
DOS-1898-f-I (Rev.01/10) Page of Deceased 1 of 3
4
I am/we are the person(s) having priority under Public Health Law section 4201 and have the right to authorize ktA
cremation of the remains of the deceased. My/Our relationship to the deceased is as follows:
(Insert from the list below)
Number: 3 Description: ,
1. A person designated in writing pursuant to Public Health Law section 4201(3);
2. The surviving spouse;
2a. The surviving domestic partner;
4Any 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 the following)
Qc
f I/We hereby affirm that the body of the deceased does not contain a battery, battery pack, power cell,
tive 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.
I/We hereby affirm that instructions have been given (funeral director name u• '� �� aeL
garding the removal of any personal property or other thing alue.frhich any person signing below or any family
member of the deceased wishes to preserve. (crematory name) (k.P 1-0-1VS 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 estroyed by the cremation process and cannot be retrieved
after cremation. ` /^
I/We hereby authorize (crematory name) 11"-e V I "P.lAr ' 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: V-(2T,4 ct-- � AtClOA,k i\ _
Address: 65 Q / teal, Ga.044Phone: -67-i( i q
The cremated remains of deceased will be disposed of as follows:
17DLthitL Sf. 1Juq1s al)17A-4
If for any reaso410e,peron named above does not take possession of the cremated remains,
(crematory name) VID Vi OAF- is authorized to give possession of the remains to
(funeral home name) Q.f�( `� l �Ut� by delivery in person or by registered mail.
DOS-1898-f-I (Rev.01/10) Name of Deceased Page 2 of 3
• Y.
(Initial the following)
I/We dergand that if the remains are not claimed within 120 days of cremation,
crematory name) ehQ I au--
may dispose of the remains in an irretrievable manner,
such as by scattering.
CREMATION CONTAINER/URN
(Initial ONE of the following)
An urn to be used as a container for the cremated remains has been purchased from
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.
An urn has not yet been purchased. I/We understand that if no urn is purchased or otherwise provided
atoryname) will place the cremated remains in a rigid temporary
container for delivery.
This Authorization Form was provided by (funeral Iirectorname) 6tti.btA.e OQot.e-A/r
was executed at(funeral(hn m�e�nn�aa�Am�Ae) �,� i `� (241 I 1 G
(funeral home address) 63 CZ uewWt /(� !�
tt�(,4kIZ(J�I�J, -�• /d�f 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.
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Signed this 1 day of . a46I 20 l y
it/l1ca4eL tred.ed O - J
Typed or Printed Name S� ature CC
2 6 Via/111W..471.� •u`'� ,vr /acfee Lev
Address
Typed or Printed Name Signature
Address
Typed or Printed Name Signature
Address
WIT SS:
Aja& . 6eo�
Funeral Director Typed o rinted Name Funeral Director Signature
0 NO of
Registration Number
4 ctucke
DOS-1898-f-I (Rev.01/10) Name of Deceased Page 3 of 3