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Cook, Karin E Pine View Cemetery & Crematorium Quaker Road Queensbury, NY 12804 (518) 745-4477 or (518) 745-4476 FUNERAL HOME: RETURN TIME: .......... DATE & TIME REMAINS ARRIVED AT CREMATORY; _ I 2.(1.1_22 NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS: . ..... NAME: ORT,n) 'oo CASE # ......_ ' TYPE OF CONTAINER: .F1.4)tf 4tA ("5 PLACE OF DEATH: 5 C/ ()Or.f- 7.6.. . thC62- . . . ..... ESTIMATED WEIGHT OF REMAINS & CONTAINER Z PLACED IN HOLD: . _ PLACED IN REFRIGERATION: ; SO fLII ._ DATE OF CREMATION: 2)4117 _ . TIME STARTED: TIME COMPLETED: PLACED IN RETORT: MOVED: RETORT # IN WHICH REMAINS WERE CREMATED: _foar,f4 Phicri DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOU& FROM TIME OF ACCEPTED DELIVERY: NOTE: THE CREMATION LOG SHALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY. New York State rriNEW YORK Division of Department of State CEMETERIES STATE OF DMSION OF CEMETERIES OPPORTUNITY Cemeteries One Commerce Plaza 1�19 Albany, NY 12231-0001 Telephone:1518)4746226 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: z/zN )/2 Number. 172 Crematory Name:Pine View Crematory Address: 21 Qv (Zo P i) t/t,t/J*/�� P (z'0 y Phone: (it' 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 Jett behind The crematory we 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 wilt be conducted before a witness and will be done in privacy,with dignity and respect IDENTIFICATION OF DECEASED Name of Deceased: KA I-;/ ) Coo /L Marital Status: Mk. Last Known Address:/ S_ r) uUeadc©m 6 jO,Y Place of Death: -S7 ky- gam; /UP.cv[.om- V, Ser D M EXF Age: .7Q DOB: (JS1Q9//�s/ Date of Death: G 4a.31 aoa - Estimated Weight 2Ls Description of casket/container in which remains will be delivered. 7 /OY e N C-4- er a m AT;i•w O P T- PIN-- 14 N e 4-- PERSON IN CONTROL OF DISPOSITION (Person(s)in control of disposition,initial ONE of the following) are, deal a ated in • m to Public -ORS r - have no knowledge that the deceased executed a written instrument pursuant to Public Health Law Section 4201 or a •II 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: (Name ataxessed) DOS-1898-f(Rev.08n5) Page 1 of 3 Authorization for Cremation and Disposition (Insert from the list below) Number. Description: 3 pet.).5 e_— 1. A person designated in writing pursuant to Public Health Law Section 4201(3); 2. The surviving spouse; 2a. The surviving domestic partner; 3. My 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. My 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 Surmgate'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). " THREE of the following) 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. 4411.1, - affirm that instructions have been given to t l d 44/ ,.r. r i regarding the removal of any personal property or other thing of value which any person signing bel or any family member of the deceased wishes to preserve. Pine View Crematory fOematery NNW Is not responsible for the removal of personal items from the container or from the remains of the deceased. Personal items left In the conta ner or with the remains will be destroyed by the cremation process and cannot be retrieved after cremation. 7 � _ UYlfe hereby authorizePine View Crematory (Oirmakxy 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:Any Staff from the Edward L Kelly Funeral Home Address: 1019 US Rt.9 PO Box 548,Schroon Lake,NY 12870 Phone:518-532 7177 The cremated remains of deceased will be disposed of as follows: Yet rti 10 A ,e.��..'A rd co.) 5/,-, 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 (Funeral Edward L Kelly Funeral Home by delivery ome Name) in person or by registered mail. kk)s)--; e, etv DOS-1898-f(Rev.08/15) Page 2 of 3 ti Authorization for Cremation and Disposition (1 /. e t lowing) e understand that if the remains are not claimed within 120 days of cremation, Pine View Crematory � � may dispose of the remains in (Nonean irretrievable manner,such as by scattering. CRENIAJlON CONTAINER/URN (Initial ONE of the following) An to be used-as'a tainer for the cremated p lf Edward une Ho a d�is desail�d ��— follows: UWe and if the urn is too all to hold the anti ated ins,an additional rigid container may be used for delivery. -OR is not yet purchased_ I/We understand that if no urn is purchased or otherwise provided t ( A y will place the cremated remains in or crewels a rigid temporary container for delivery. /�� This Authorization Form was provided by -6 4i') 4 7�N t y` was executed at (RmeratlYredOr Edward L Kelly Funeral Home Funeral Horne Nemo) 1019 US Rt 9,PO Box 548 Schroon Lake,NY 12870 tFteread Hone Address) and is signed by the funeral director as witness to its execution. 1/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(*)the foregoing. Sig this a3 Jc of ,20 or typed or Printed Name Volum Address Typed orPrfored Nine SiOnature Address WITNESS: ZeZ/, (FtmelatOirectorTypedD►P 's:adNene) tasO lon /l / fI /V � Cd of DOS-1898-f(Rev.08/15) Page 3 of 3