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Parrott, Richard J • Pine View Cemetery 8. Crematorium Quaker Road Queensbury, NY 12804 (518) 745-4477 or (518) 745-4476 FUNERAL HOME: _ RETURN TIME: ----- - DATE & TIME REMAINS ARRIVED AT CREMATORY; 21/1 /Z Z- /td°fril NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS: NAME: iqtatlep. TYPE OF CONTAINER: Flo•'N, 641617t- ‘:... 14061 °-111 PLACE OF DEATH: 113) OUtek. Fc)/4 _ rig t,7 ESTIMATED WEIGHT OF REMAINS & CONTAINER PLACED IN HOLD: - - PLACED IN REFRIGERATION: /1;6_41-1 DATE OF CREMATION: Zh9 I Z2- TIME STARTED: t, n TIME COMPLETED: 2:ien PLACED IN RETORT: MOVED: cMr RETORT It IN WHICH REMAINS WERE CREMATED: Sqf EC __Tovitp,„1111C _ DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS FROM TIME OF ACCEPTED DELIVERY: NOTE: THE CREMATION LOG SHALL DE RETAINED IN THE PERMANENT FILE OF THE CREMATORY. New York State Department of State NEW YORK ' Division of DIVISION OF CEMETERIES STATE OF One Commerce Plaza OPPORTUNITY. Cemeteries leteries 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: Fcb. 13, 2022 Number: t I Crematory Name: T I4(VA.l (v.tto Address: 2( ()Adv. (Zobj Crvit,3 bury P. 1T °1 Phone: (.Sl$) wa 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: Richard J. Parrott Marital Status:Widowed Last Known Address: 1133 Co. Rte. 16, Fort Ann, NY. 12827 Place of Death: Same as Ahnve Sex: ®M ❑ F Age: 93 yD&ii: 6/2 7/1 9 2 8 Date of Death: 2/1 2/2022 Estimated Weight: 1a Description of casket/container in which remains will be delivered. Florence Casket Co. wood, woodcomposite base, cardboard top. 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. 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 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: Richard J. Parrott (Name d Deceased) DOS-1898-f(Rev. 08/15) Page 1 of 3 Authorization for Cremation and Disposition (Insert from the list below) Number: 3 Description: OR HTrR 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) gaI/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. gaI/We affirm that instructions have been given to Bruce K. Mason, 12261 (Funeral Dimctor 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. T i4� V tW (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. o.�• I/We hereby authorize , AR Yam+ (Crematory Name) 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: Bruce K. Mason Address: P.O. Box 277, Fort Ann, NY. 12827 Phone: 518-639-5252 The cremated remains of deceased will be disposed of as follows: Return to family. If for any reason the person named above does not take possession of the cremated remains, ?l o j is authorized to give possession of °I (CrematoryName) the remains to Mason Funeral Home by delivery (Funeral Home Nano) in person or by registered mail. Richard J. Parrott (Name of Deceased) DOS-1898-f(Rev. 08/15) Page 2 of 3 Authorization for Cremation and Disposition ©nitj�l th2 following) I/We understand that if the remains are not claimed within 120 days of cremation, RAt�t'.) may dispose of the remains in (Name of Crenetory) an irretrievable manner, such as by scattering. CREMATION CONTAINER/URN (Inipl Oly�'of the following) (/�/') An urn to be used as a container for the cremated remains has been purchased from Mason Funeral Home and is described as follows:Ea g] e Urns-Cultured Granite with Mtn. Scene 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 is not yet purchased. I/We understand that if no urn is purchased or otherwise provided "R u OIL will place the cremated remains in (Name of Crematory) a rigid temporary container for delivery. This Authorization Form was provided by Bruce K. Mason, 1 2261 was executed at (Funeral Director Name) Mason Funeral Home (Funeral Home Name) 18 George St. , Fort Ann, NY. 12827 (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. Sign this ,^�/1 3 th day ofrFebru xy ,20 Ceg. L- ,ci tero (1 %��/ .1 beCC- _ ,t/t Typed a Pnnted Name Signature 702 Co. Rte. 16, Fort Ann, NY. 12827 Address Typed a Printed Name Signature Address Typed a Printed Name Signature Address WITNESS: Bruce K.Mason (Funeral Director Typed a Printed Alarm) (Funeral Director Signature) (Registration ain2e261 Richard J. Parrott (Name of Deceased) DOS-1898-f(Rev.08/15) Page 3 of 3 Pine View Cemetery and Crematorium 21 Quaker Road Queetisbury, NY 128Ud• Authorization to Separate Cremated Remains Funeral Home M1�5a1J --- --- ... --- Director -- - - - --- �� L�►� - - Date z 1_11J -- - 1,1 N o. I/we authorize the separation of the cremated remains of I./we Iurther agree to hold harmless, indeinl,il•y and defend the herein named crematorium as well its their representatives, h'olll anCI against all claims, liabilities o1' damages whatsoever which may result from this aul.horiration. f Sigmit.urc --- Crematory Operator �-- ---- March 2015