Mitchell, Robin Hensley Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: --___. !° > GA►1...__�.._ N 16E-4-5flti-c_ RETURN TIME: NONE
DATE & TIME REMAINS ARRIVED AT CREMATORY: . ._,.._,
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
-• �'0 .
NAME:
_....._...._._ J..........►' ..... L(,. ._......_....__...._...._._............__........._......_.. -- ._....._...._.CASE # __ 7
TYPE OF CONTAINER: .........__.._.._...._0_41 S 2 A_._._...I tU E JGLI1f\D.........64110042,,ARp
POlil
PLACE OF DEATH: _......_.. 5Arilt06..4.... 14 t l_...._......._...............-_._ - ... .
ESTIMATED WEIGHT OF REMAINS & CONTAINER
600.4Lql ...._..._
PLACED IN HOLD:
_
PLACED IN REFRIGERATION: __._..._ ,__ .--
DATE OF CREMATION: a.-gk-.7 .'x,,Z .........................----._...._.__.__........._._. ..
TIME STARTED: ....' ......._.......... TIME COMPLETED: / rf ._............ .
PLACED IN RETORT: Rv _ MOVED: 1 0.it
RETORT it IN WHICH REMAINS WERE CREMATED:
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SHALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
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.ny.us
This Authorization Form must be completed and signed prior to delivery of remains for cremation.
Date: a /d'-J ic)04.)
Number: 11
Crematory Name: 1'i f-e. V i ew Cre r A-641
Address: d, Quaw zoC.c d 1 (a,eer>Siovey Ny 1 zVOLI Phone: `515) 1 y5- 4416
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 um. 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 ll
Name of Deceased: 'i ,c r 4en5}ty IM{-t;he% Marital Status: Wt'ckvvecJ
Last Known Address: WI Kira tit. rata � 5p-r➢r c , )2g(L
Place of Death: Sarat-or 1osp -w. i 5 ra-#dot Spc ingS, NY j zA,
Sex: ❑M OF Age: (oO DOB: 9-I 8-lq(:A Date of Death:a J d3 /Yi Estimated Weight: (p00 lbs.
Description of casket/container in which remains will be delivered:
o stzep wF� Ir p �t cNF. ��RP o1\RO
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.
_e
• I/We have no knowledge that the deceased executed a written instrument pursuant to Public Health Law
s"T�n 4201 or a will containing directions for the disposition of his or her remains and (Continued next page)
'l oh;r 4 siey M3+c4. i
DOS-1898-f-1 (Rev.12/11) Name of Deceased Page 1 of 3
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. MylOur relationship to the deceased is as follows:
(Insert from the list below)
Number: 3 Description: 5J,,,;,.;,,,3 C1.i',A
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).
(I • LL THREE of the following)
I/We hereby affirm that the body of the deceased does not contain a battery, battery pack, power cell,
ctive 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
cre • personnel. II
it I/We hereby affirm that instructions have been given to(funeral&actor name) NI i chcs i as 'b- laCtal1K
- 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. (crematory name)_ri ne Vrom Ct t.Y •ti is not
responsible for removal of personal items from the container or from the remains of the deceased. Personal item_
by the cremationand retrieved
:eii in the container or with the remains will be destroyedprocess cannotbe retrieved
�� v
at" -ma ion.
�.r►c v i tw ' o r to cremate the
. "'e hereby authorize tcremaroyynames Cr-E''n.0 y
r 'r's of the deceased.
FINAL DISPOSITION
The person authorized to receive the cremated remains of the deceased from the crematory is:
Name: W,•lliwri, ..l• (Rixtf e 4 Se.*`5 F. H
Address: 1�r r,al,.,a.-1 1 c ex., 3" S9 f i 4 ) ivy Phone: sir- 579- 531 3
The cremated remains of deceased will be disposed of as follows: J 2eld,
froed To FtNLL1
If for any reason the person named above does not take possession of the cremated remains,
(crematory name) �i Y1-e. V(-OW CX-C,r-- Ocie--3 r-'1 is authorized to give possession of the remains to
(funeral home name) W 1'I 1 i)01�1 T. ktv-i .e s 1c H'- by delivery in person or by registered mail.
ohi t, 4.).c rsl-es,' ni 14 C,J Cl 1
Name of Deceased Page 2 of 3
DOS-1898-f-I (Rev.01/10)
•
e following)
I/We understand that if the remains are not claimed within 120 days of cremation,
(crematory name) I'7;n e VK Creyrzoke 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
(crematory name) Pc-n-c Vicw CrtMer/1r will place the cremated remains in a rigid temporary
container for delivery.
This Authorization Form was provided by(funeral director name) lJi aa las b. atCei
was executed at(funeral home name) W i L l i arN S gurKe Zois Fimeeio,
(funeral home address) (Dag AJ. Rtoac(wai ca-terk Sp-c0A11) (Vl' and is signed by the funeral director
as witness to its execution. ) gw.
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 Fora,attests)to the accuracy and completeness of the information contained in this
Authorization Form Lrre utttrize(5i1 the foregoing.
Signed this dy day of g.6ruc,rr7 20 d2it 11-th /7^
Printed .lam atu e�
Typed or, ,;nt.,.,Name S;�
(vl Kfn ad. .cut' a Spci,- c , ..,, W 12-%(o
Address
Typed or Printed Name Signature
Address
Typed or Printed Name Signature
Address
WITNESS:
MthO/45 beteal -AUdviii. JO- ,Dt. CA 1.4
Funeral Director Typed or Printed Name Funeral Director Signature
►415i
Registration Number
ft/t )-dcut
DOS-1898-f-I (Rev.01/10)
Name of Deceased Page 3 of 3