Normandin, Helen Clarie •
Pine View Cemetery 8. Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME:
RETURN TIME: T1)Aq.),
DATE & TIME REMAINS ARRIVED AT CREMATORY: „also
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
_PAct_c k
NAME: klYrk fS11,40-\
CASE-- -
TYPE OF CONTAINER: :31.k_..A .C.(910_ cf./ _ _Cce/4
PLACE OF DEATH:efiNt_ d()_(_. gt+ _Co .41C_Sitsjd ..kakt?_;1;ifd:DA
ESTIMATED WEIGHT OF REMAINS & CONTAINER t?•• _015
PLACED IN HOLD: _
PLACED IN REFRIGERATION:
DATE OF CREMATION: a 0 -27,
TIME STARTED: Ai‘A TIME COMPLETED:
PLACED IN RETORT: _11,43 41N. //"N-1-(11?"` MOVED:
RETORT # IN WHICH REMAINS WERE CREMATED:
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 40 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SHALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
• , New York State
Department of State
fr-INEW YORK Division of DIVISION OF CEMETERIES
STATE OF One Commerce Plaza
OPPORTUNITY. 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: 02/06/2022 Number: `i
Crematory Name:Pine View Crematory
Address:Quaker Road, Queensbury, NY 12804 Phone: (518) 745-4476
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 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 DECEASED
Name of Deceased: Helyn Claire Normandin Marital Status: Widowed
Last Known Address:170 Warren Street, Glens Falls , NY 12801
Place of Death:The Pines At Glens Falls, 170 Warren Strret, Glens Falls, , NY 12801
Sex: 0 M ® F Age: 76 DOB: 06/28/1945 Date of Death: 02/05/2022 Estimated Weight: eQ C 51
Description of casket/container in which remains will be delivered.
Buffalo casket Company—Alt container
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 Section 4201 or a
ill containing directions for the disposition of his or her remains and I/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:
Helyn Claire Normandin
(Name of Deceased)
DOS-1898-f(Rev. 04/20) Page 1 of 3
4A-Itr,
.Authorization for Cremation and Disposition
(Insert from the list below)
Number: 3 Description:Child over the age of 18
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 Section 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 Section 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, 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.
I/We affirm that instructions have been given to Mark J. DeSimone
(Funeral Director Name)
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
(Crematory 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
container or with the remains will be destroyed by the cremation process and cannot be retrieved after cremation.
49_I/We hereby authorize Pine View Crematory
(Crematory Name)
to cremate the remains of the deceased.
(Initial OPTIONAL)
I/we hereby authorize the named funeral director to provide for delivery to and cremation by an alternate
crematory,if deemed necessary in the opinion of the funeral director,and to amend this form to provide the correct name and
address of such alternate crematory.
FINAL DISPOSITION
The person authorized to receive the cremated remains of the deceased from the crematory is:
Name:George Normandin
Address: 20 Hughes Court, Queensbury, NY 12804- Phone: (518) 791-4597
The cremated remains of deceased will be disposed of as follows:
Burial at Saratoga National Cemetery
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
(Crematory Name)
the remains to Singleton Sullivan Potter Funeral Home by delivery
(Funeral Home Name)
in person or by registered mail. Helyn Claire Normandin
(Name of Deceased)
DOS-1898-f(Rev. 04/20) Page 2 of 3
41K
'Authorization for Cremation and Disposition
(Initial the following)
�r / —
I/We understand that if the remains are not claimed wit"
12 ays of cremation,
Pine View Crematory may dispose of the remains in
(Name of Crematory)
an irretrievable manner,such as by scattering.
CREMATION CONTAINER/URN
(Initial ONE of the following)
Singleton Sullivan Potter
An urn to be used as a container for the cremated remains has been purchased from F,,nor•&i Nr,r„o
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 is not yet purchased. I/We understand that if no urn is purchased or otherwise provided
Pine View Crematory will place the cremated remains in
(Name of Crematory)
a rigid temporary container for delivery.
This Authorization Form was provided by Mark J. DeSimone was executed at
(Funeral Director Name)
Singleton Sullivan Potter Funeral Home
(Funeral Home Name)
407 Bay Road, Queensbury, NY 12804
(Funeral Home Address)
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 6th day of February ,20 22
George Normandin 3 _
Typed or Printed Name Signature
20 Hughes Court, Queensbury, NY 12804-
Address
Typed or Printed Name Signature
Address
Typed or Printed Name Signature
Address
WITNESS:
Mark J. DeSimone ru ti.
(Funeral Director Typed or Printed Name) (Funeral Director Signature)
10919
(Registration Number)
Helyn Claire Normandin
(Name of Deceased)
DOS-1898-f(Rev. 04/20) Page 3 of 3
DOH-1961(8/2011) RECORDED DISTRICT NEW YORK STATE -4/ 116
5601 DEPARTMENT OF HEALTH
REGISTER NUMBER 131-2022-00013799
CERTIFICATE OF DEATH
83 STATE FILE NUMBER
1.NAME:FIRST MIDDLE LAST 2.SEX: 3A.DATE OF DEATH: 13B.HOUR:
MALE FEMALE MONTH DAY YEAR
Helen Claire Normandin AKA Helyn Claire Normandin ❑i ®2 02 I 05 2022 I 11:57 AM
4A.PLACE OF DEATH: HOSPITAL HOSPITAL HOSPITAL NURSING PRIVATE HOSPICE OTHER 14B.IF FACILITY,DATE ADMITTED:H DAY YEAR
(Check one) DOA ER OUTPATIENT INPATIENT HOME RESIDENCE FACILITY (Specify):
❑ ❑ 0 0 ® 0 0 0 II
12 07 2021
I40.LOCALITY:(Check one and specify) I 4E.COUNTY OF DEATH:
4C.NAME OF FACILITY:!If not facility,give address) I CITY VILLAGE TOWN I
The Pines At Glens Falls Center For Nursing&Rehabilital ❑ ❑ ❑ Glens Falls I Warren
4F.MEDICAL RECORD NO. 1I4G.WANDDECEDENT TTRANSFERRED FROM ANOTHER INSTITUTION?(If yes,specify institution name,city or town,county and state)
13 143660 I ❑ ® Glens Falls Hospital,Glens Falls,Warren,New York
a .0 5.DATE OF BIRTH: 6A.AGE IN 6B.IF UNDER 1 YEAR 6C.IF UNDER 1 DAY 7A.CITY AND STATE OF BIRTH:(If not USA,Country and 7B.IF AGE UNDER 1 YEAR,NAME OF HOSPITAL OF
w YEARS: ENTER: ENTER: Region/Province) BIRTH:
6 MONTH DAY YEAR months days hours minutes
V 76 1 1
0 I I
06 28 1945 y s, I I Corinth Town,New York
V 1H B.SERVED IN U.B.ARMED 9.DECEDENT OF HISPANIC ORIGIN?Check the boxes that boo describe whether the decedent is Spa ksh'HispaniAadro 10.DECEDENT'S RACE:Check one Wmoe aces to indicate whatme decedent consideredhmsedp terse*mbe:
Z m i+ Z FORCES?(Specify. years) A[K No,not S anish/Hispanic/Latino B❑Yes.Mexican.Mexican American,Chicano
H C w NO YES pA®WhAelCaucasian B❑Black or Atdcan American C❑Asian Indian D❑Chinese
a IR Q) E ®0 ❑1 c❑Yes.Puerto Rican D❑Yes,Cuban
4) IX U E❑Wino F❑Japanese G❑Korean H Vietnamese
r AS c LLl el 0 E❑Yes,Other Spanish/Hispanic/Latino(Specify) J❑Native Hawaiian K 0 Guamanian or Chamorro M❑Samoan
11.DECEDENT'S EDUCATION:Check the boxdar best describes the highest degree or level of school cmnpetedatthe time of death. N❑American Indian or Alaska Native(specify)
1 0 5 8th grade 2 0 9th-12Hn grade:no diploma 3®High school graduate or GED
▪ O4❑Some college credit,but no degree 5❑Associate's degree 6❑Bachelors degree P❑Other Asian(specify) R❑Other Pacific Islander(specify)
VCU L 7 0 Master's degree 8❑Doctorate/Professional degree S❑Other(specify)
H t >v5„ 12.SOCIAL SECURITY NUMBER: 13.MARITAL STATUS: 14.SURVIVING SPOUSE:
ir+ NEVER MARRIED MARRIED WIDOWED DIVORCED SEPARATED Enter birth name of spouse
t et. H 086-36-2000 ❑1 0 2 IM 3 ❑4 0 5 if married or separated.
co e5 15A.USUAL OCCUPATION:(Do not enter retired) 1158.KIND OF BUSINESS OR INDUSTRY: i 15C.NAME AND LOCALITY OF COMPANY OR FIRM:
Ili Receptionist I Home Remodeling 'Home Improvement Gallery,So Glens Falls,NY
1- C 16A.RESIDENCE: 168.County or Region/Province 16C.LOCALITY:(Check one and specify) 16F.IF CITY OR VILLAGE,IS RESIDENCE
O (State or Country if not USA: CITY VILLAGE TOWN WITHIN CITY OR VILLAGE LIMITS?
Z if not USA) NY Warren 0 0 0 Glens Falls ID YES ONO IF NO,SPECIFY TOWN:
16D.STREET AND NUMBER OF RESIDENCE: 1I 16E.ZIP CODE:
170 Warren Street
112801
17.BIRTH NAME OF FIRST MI LAST 18.BIRTH NAME OF FIRST MI LAST
FATHER/PARENT: MOTHER/PARENT:
Howard C Wendell Eva May Dingman
19A.NAME OF INFORMANT: 119B.MAILING ADDRESS:(include zip code)
George Normandin 120 Hughes Court,Queensbury,NY 12804
20A.1 I BURIAL 2 RICREMATION 31D EMHAL 4 OHHOLD Y 50 DONATION120B.PLACE OF BURIAL.CREMATION,REMOVAL OR OTHER DISPOSITION. 120C.LOCATION:(City or town and state)
MOYEAR
z 6OENTOMBMENT I I QueensburyTown,New York
02 08 2022 I Pine View Crematory t
l- 21A.NAME AND ADDRESS OF FUNERAL HOME: 121B.REGISTRATION NUMBER:
N Singleton Sullivan Potter Funeral Home j01596
407 Bay Rd,Queensbury,NY 12804 1
CO 0 22A.NAME OF FUNERAL DIRECTOR: 122B.SIGNATURE OF FUNERAL DIRECTOR: 1I 22C.REGISTRATION NUMBER:
Mark J DeSimone I 1 Mark9uDeSimone U(ectronicaffySigned I10919
23A.SIGNATURE OF REGISTRAR: 123B,DATE FILED:MONTH DAY YEAR 124A.BURIAL OR REMOVAL PERMIT ISSUED BY: 124ABDA ISSUED: YEAR
' I I I
ITEMS 25 THRU 33 COMPLETED BY CERTIFYING PHYSICIAN-OR-CORONER/CORONER'S PHYSICIAN OR MEDICAL EXAMINER
25A.CERTIFICATION: To the best of my knowledge,death occurred at the time,date and place and due to the causes stated.
Certifier's Name: License No.: Signature: Month Day Year
Courtney Diamond,laCourtney Diamond,NP 1338765 I► rE(ectronicaffySigned 02 06 2022
Certifier's Title: 0❑Attending Physician 0❑Physician acting on behalf of Attending Physician Address:
w_ 1❑Coroner 2❑Medical Examiner/Deputy Medical Examiner 170 Warren St,Glens Falls,NY 12801
1 25B.It coroner is not a physician.enter Coroner's Physician's name&title: License No.: Signature: Month Day Year
I- 11.
CC
0 25C.H certifier is not attending physician.enter Attending Physician's name&title: License No.: Address:
26A.Attending physician Month Da Year Month Dav Year 26B.Deceased last seen alive Month Day Year 26c.Pmunouemd Month Day Year lime
attended deceased: FROM 01 09 2017 to 02 05 2022 by attending physician: 01 29 2022 Dead Ott 02 1 05 1 2022 la 11:57 AM
27.MANNER OF DEATH: UNDETERMINED PENDING 28.WAS CASE REFERRED TO 29A.AUTOPSY? 129B.IF YES,WERE FINDINGS USED TO DETERMINE
NATURAL CAUSE ACCIDENT HOMICIDE SUICIDE CIRCUMSTANCES INVESTIGATION CORONER OR MEDICAL EXAMINER? NO YES REFUSED I CAUSE OF DEATH?
®1 02 03 04 05 06 0®NO 1❑YES ®0 01 02 I 00NO 1❑YES
CONFIDENTIAL SEE INSTRUCTION SHEET FOR COMPLETING CAUSE OF DEATH CONFIDENTIAL
APPROXIMATE INTERVAL
30.DEATH WAS CAUSED BY:(ENTER ONLY ONE CAUSE PER LINE FOR(A),(B),AND(C).) BETWEEN ONSET AND DEATH
PART I.IMMEDIATE CAUSE: 1 hour
(A)Cardiopulmonary failure
= DUE TO OR AS A CONSEQUENCE OF: 6 years
I- (B)Chronic Kidney Disease
o DUE TO OR AS A CONSEOUENCE OF: 6 years
6 (C)Type 2 Diabetes
PART II.OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO DID TOBACCO USE CONTRIBUTE TO DEATH?
w DEATH BUT NOT RELATED TO CAUSE GIVEN IN PART I(A):<<<>>> 0®NO 1❑YES 2❑PROBABLY 3❑UNKNOWN
n 131 D.PLACE OF INJURY: 131E.INJURY AT WORK?
I HOUR: 131 B.INJURY LOCALITY:(City or town and county and state) 131C.DESCRIBE HOW INJURY OCCURRED:
Q• MONTHF INJURY,AAYDATE: I I I I ; NO YES
✓ I I I II 1❑0 01
I I I
31F.IF TRANSPORTATION INJURY,SPECIFY: 32.WAS DECEDENT 33A.IF FEMALE: 33MB.DATE OF DELIVERY. YEAR
10Driver/Opeator 20Passenger 30 Pedestrian HOSPITALIZED IN NO YES 0®Not pregnant within last year 1❑Pregnant at time ofdeath 2❑Not pregnant,but pregnant within 42 days ofdeath
LAST 2 MONTHS?
4❑OTHER(specify) ❑0 0J1 3❑Not pregnant.bet pregnant 43 days to 1 year before death 4 Unknown N pregnant within past year