Constantine, Albert Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: CACit,i(In
RETURN TIME: giVit,
DATE & TIME REMAINS ARRIVED AT CREMATORY; 02--/0-?'0)--7- Ryn
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
NAME: ALS)-e..57_1 nes,
CASE # _
TYPE OF CONTAINER: digAtm, S. __PI.R.QA:Lber4rY, (4.441" G9 rilaWd
PLACE OF DEATH: _ 91_6 ..4"44:1401\ _
ESTIMATED WEIGHT OF REMAINS & CONTAINER P1bs _
PLACED IN HOLD:
PLACED IN REFRIGERATION: IQ;05)."
DATE OF CREMATION:
TIME STARTED: irrY TIME COMPLETED: a:61N
PLACED IN RETORT: /y.l_Stitn MOVED:
RETORT n IN WHICH REMAINS WERE CREMATED: bvo_S- _
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 40 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SHALL DE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
ik 131 NYS Department of State
Authorization 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: February 9, 2022 Number: =tC 13
crematory Name: Pine View Crematorium
Address: Quaker Road, Queensbury, NY 12804 Phone:S11'S ? is La7?
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.
DPENING OF CONTAINER.
[he 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
lamage crematory property. If human remains are delivered in a container which is not suitable for cremation
;Lich as a ceremonial or rental casket, the crematory will require that the remains be moved into a suitable
:ontainer before it accepts the remains. The opening of a container or the transfer or removal of remains will be
;onducted before a witness and will be done in privacy, with dignity and respect.
DENTIFICATION OF DECEASED
\lame of Deceased: Albert Constantine Marital Status: widow
_ast Known Address: Homeless
place of Death: Glens Falls Hospital
Sex 110 F Age: 61 DOB: 9/10/1960 Date of Death: 2/5/2022 Estimated Weight: /20
Description of casket/container in which remains will be delivered:
Vlatthews Cremation Case plywood bottom with cardboard top
'ERSON 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
)ursuant to Public Health Law section 4201.
•OR-
/rii /We have no knowledge that the deceased executed a written instrument pursuant to Public Health Law
>�c o' 4201 or a will containing directions for the disposition of his or her remains and (Continued next page)
Albert Constantine
SOS-1898-f-I(Rev.01/10) Name of Deceased Page 1 of 3
*I3)
I am/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/Our relationship to the deceased is as follows:
(Insert from the list below)
Number: 3 Description: Step-son
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 the following)
/,,// I/We hereby affirm that the body of the deceased does not contain a battery, battery pack, power cell,
.a•ioactive 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
;rematory personnel.
��Z I/We hereby affirm that instructions have been given to (funeral director name) Lance Evans
egarding the removal of any personal property or other thing of value which any person signing below or any family
nember of the deceased wishes to preserve. (crematory name) Pine View Crematorium is not
esponsible for removal of personal items from the container or from the remains of the deceased. Personal items
eft in the container or with the remains will be destroyed by the cremation process and cannot be retrieved
tfter cremation.
I/We hereby authorize (crematory name) Pine View Crematorium to cremate the
ns of the deceased.
=INAL DISPOSITION
The person authorized to receive the cremated remains of the deceased from the crematory is:
Jame: Carleton Funeral Home, Inc.
Nddress: 68 Main Street, Hudson Falls, NY 12839 Phone: 518-747-4243
The cremated remains of deceased will be disposed of as follows:
returned to family
f for any reason the person named above does not take possession of the cremated remains,
crematory name) Pine View Crematory is authorized to give possession of the remains to
funeral home name) Carleton Funeral Home, Inc. by delivery in person or by registered mail.
Albert Constantine
)OS-1898-f-I(Rev.01/10) Name of Deceased Page 2 of 3
1-13
(Initial the following)
1 I/We understand that if the remains are not claimed within 120 days of cremation,
(crem Cory name) Pine View Crematorium 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
Carleton Funeral Home, Inc.. 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
(rematory name) Pine View Crematorium will place the cremated remains in a rigid temporary
container for delivery.
The Authorization Form was provided by (funeral director name) Lance Evans
was executed at (funeral home name) Carleton Funeral Home, Inc.
(funeral home address) 68 Main Street, Hudson Falls, NY 12839 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.
Signed this day of / 20 20 .4;27r.._
1.Alfred Lamb*jjj NT* /
Typed or Printed Name Signatur-
88 Oak Street, Hudson Falls, NY 12839
Address
Typed or Printed Name Signature
Address
Typed or Printed Name Signature
Address
WITNESS:
Lance Evans r�
Funeral Director Typed or Printed Name uneral Direct ignature
/ O,�
Registration Number
Albert Constantine