Ruane, Hugh F Jr. •
Town of Queensbury
Pine View Cemetery and Crematoriurit' •
Quaker Road, Queensbury, NY 12804
(518) 745-4476 or (518) 745-4477
Funeral Director
Name u5L t� u'�+u �. Case No. 1
Date of Cremation ` 1,404,r 3 Z o
T,me Cremation Started
Tame Cremation Completed . 7`
Type of Container mLeevil co W'u'avO 4x
Remarks ZS�� t6'ph
MZ<<
Pine View Crematory Log
(1) Name of the Deceased i f io5L tAA4, Tyr-
(2) Place of Death - +b Iiay..ti,,h (tut et }-14clIv) Mf , I Z ¶36`
Estimated weight of remains and container
o s LBS
(3) Date and Time remains arrived at the Crematory
041kAri 3, Z0 (Z ii3-At
(4) Cremation Number $
(5) Name of funeral director, undertaker or registered resident
delivering remains, and the address of the funeral firm
Rib Dislooq
Ct'r; J,i z 2
(6) Date and Time remains were cremated
3, Lo,Z 1 rP►�
(7) Detailed reason for the delay if the remains were cremated
more than 48 hours from time of accepted delivery
(8) Retort Number in which remains were cremated
C 2,A u(2 0
(9) Type of container in which remains were received and in
which the remains were cremated
Crc114>Ad
Note: The Cremation Log shall be retained in the Permanent File of
the Crematory
I 'Aua::ortzatibn for Cremation and Disposition NYS Department of State
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: sic- . 3 I oZ o I( Number:
Crematory Name: PA c v;c,.„� r j�C ,.., K-1-,►�
��K leck
Address: ,_ A>L,.A 1 P -7 Phone:? - .7r
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 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
Name of Deceased: H K r"`1 4 e -5-R• Marital Status: c.: V o rce-k
Last Known Address: /3 U /ti o y,1--,...;,^ /c-dl ���� /l1 I / � ��S
)1 /
Place of Death: (.SkMe 6-2_ , ✓e)
Sex: 'l M ❑F Age: 51 DOB: job /i'tc„), Date of Death: /R/3 V.,)u ii Estimated Weight..' (L
Description of casket/container in which remains will be delivered:
z
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.
•
�,/�C, I/We have no knowledge that the deceased executed a written instrumentpursuant to PublicHealth
ea th Law
section 4201 or a will containing directions for the disposition of his or her remains and (Continued next page)
Hk ki t a 4 C.--
DO S-1 898-f-I (Rev.01/10) Name oased Page 1 of 3
,
• i;niti e following)
i I/We underst d that if the remains are not claimed within 120 days of cremation,
(crematory name) ; , r V -c may dispose of the remains in an irretrievable manner,
such as by scattering.
CREMATION CONTAINER/URN
(Initial ONE of the following)
An) ir �o..be used as a container for the cremated remains has been purchased from
A.ecz43_. .5 , e 174 nee;( }-t~"—. 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.
K. !'y
aAn urn has not y een purchased. I/We understand that if no urn is purchased or otherwise provided4
(crematory name) I64-V'ii✓ will place the cremated remains in a rigid temporary
container for delivery.
This Authorization Form was provid d by (funeral director name) 61)e IA- .1 -, a_5 M„--z_
was executed at (funeral home name) 4 e__..v S,,,,,:iie-- 'I- 1-f
(funeral home address) ecu She"M r, mac, r,„-.�L( M 7 /-- gy}.�-and is signed by the funeral director
as witness to its extion.
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 day of _-fie•-.1 1 Cy- 20 L
r ,A..r 1----P AA 42_ ,
Typed'or Printed Name 'Si nature �""
I ' M4'. PI) ou 1j,,. ,f.�Y3
Address
Typed or Printed Name Signature
Address
Typed or Printed Name Signature
Address
WI NESS: _ -
Fune I irector Typed or Pri me ",---u , •�.or Signature
6a `L'b r�
Registration Number
I1...k 1,, iet„, e_____
DOS-1898-f-1 (Rev.01/10) Name of Decded Page 3 of 3