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Vaughn, Kevin J cr0 wi L of Q13'URY PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director ,SUN Name Vev,n Case# 31�� Date Of Cremation I(,`1 I'I toil Time Cremation Started Ph Time Cremation Completed c 'LISA� Type of Container g, LLd C2R OtaV Fist' Cs� Remarks mP61.) :Kr An muvc._ I. 1rkv\ 4; '3°A-i) 'A aor►ication for Cremation and Disposition h1YSMAIM DaprhnML„,ew On•caammat glM.M� n Mt +► This Authorization Form must be completed and signed prior to delivery of remains for cremation. Date: .3'llhy / ./ O./ 2-- Number: (i' 1 Crematory Name: 4'j Ile. V (f AnI 0 re.n aTo r y Address:21 GOLL,K#y kaci ( uecn ury NIy I 28011 Phone: (5i3) 14 fr '4411 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: j{,e't///l,/ .3—, ///4L/G/.1it/ Marital Status: 1n1MffL Q 1.01#/eAlogiv/./.1_ Last Known Address: //2 44)19/ 840777,STO O f,Ny /..V d a l Place of Death: S f/r/�' fig' 19 BOIJE Sex: [WM OF Age:.3? DOB:09 /G /9. ' Date of Death: 01 /. Estimated Weight:/PDg6 Description of casket/container in which remains will be delivered: 44.1000/uJ00a Cc)rl90.9iTLsa8i9SE/C/91RDa30#0?D 7? e 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. R- IIWe have no knowledge that the deceased executed ah written instrument pursuant to Public Health Law sectio 4201 or a will containing directions fCe or the disposition of his or her remains and (Continued next page) Page 1 of 3 Name of Deceased DOS-1898-f-I (Rev.12/11) I am:aiet..the person(s) having priority under Public Health Law section 4201 and have the right to authorize .Th cremation of the remains of the deceased. My/Our relationship to the deceased is as follows: _fist (Insert from the list below) Number: ov Description: al/p4 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 ALL THREE of the following) I/We hereby affirm that the body of the deceased does not contain a battery, battery pack, power cell, - • •- ; e implant,or radioactive device and that any such materials were removed prior n to the et the execution c iorenofory and of this Authorization Form. Failure to remove these items priorto cremation may 1 -m.tory personnel. I/We hereby affirm that instructions have been given to(funerar ckedor name)C 3 Rare e_ / . rn.t�_C�o�L or other thing of value which any person signing below or any family r-•a •ing the removal of any personal property �. //��rat�Y� not member of the deceased wishes to preserve. (crematory n e) 91 t or fromheremains of the dece sed. Personal isc,r;3 responsible for removal of personal items from the container to t in the container or with the remains will be destroyed by the cremation process and cannot be retrieved atter rernauon., QY io cremate the e \ Me hereby authorize(crematory name) Alt.lt. V I e 0A r.M re a - of the deceased. FINAL DISPOSITION . . The person authorized to receive the cremated remains of the deceased from the crematory is: Name: r� Phone:�..3 --��� Address: CPD• �O X V F'd fir�� N '/ /4 �.� The cremated remains of E��� sposed of as v/9�lG��follows: �7ugg� If for any reas he pe on nam above does not take possession of the cremated remains, ` � is authorized to give possession of the remains to (crematory name) hie. V i Al e YYI Y delivery in person or by registered mail. SCAT iriejl A', L /' 2� by del ry (funeral home name) inn �cJ� /j' IJ v .3"- Page 2of3 Name of Deceased DOS-1898-f-I (Rev.01/10) (Initial th- following) ���� I/We�erstand`trat if the remains are not claimed within 120 days of cremation, (., ma ry name) Vi(1 e, V i tvJ a itelYIOJ'"O r y may dispose of the remains in an irretrievable manner, such as by scattering. f 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 u has not et been purchased. I/We understand that if no urn is purchased or otherwise provided ( :,:tory name) ri i.€.. V i eve! (Ye p y will place the cremated remains in a rigid temporary container for delivery. This Authorization Form was provided by (funeral director name)63 RL/C 6 X /22O.S'4A/ was executed at(funeral home name)/YI13.9ON F/JA/laP1L , 1)'2 E (funeral home address) PORT AA/W Al y /o? cf4,1 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 /AK 7-1/f day of , 20�. ©/U5-6/4/A n.ai2a a#Ai Typed or Pr.,nted Name Sionatur //2 M/ 4)4' ePooRihL. levy �o sTO ivy./ (-fir Address • Typed or Printed Name Signature Address Typed or Printed Name Signature Address WITNESS: .63r aeg H./1219 SON Funeral Director Typed or Printed Name Funeral Director Signature c Registration Number KEv/;v U19 6-A/ Page 3 of 3 DOS-1898-f-1 (Rev.04/10) Name of Deceased • Pine View Crematory Log (1) Name of the Deceased- re,,, J )L (2) Place of Death - ,( L ')k 1 ow-wtbl weightPs �omsfoa . (Z Estimated of remains'and container Igo CB-5 (3) Date and Time remains arrived at the Crematory 0-001 IL, 7012 1115DA1 (4) Cremation Number t 3L I (5) Name of funeral director, undertaker or registered resident delivering remains, and the address of the funeral firm Bcoo ,Sv P`' �' 2 17 �A I z zl (6) Date and Time remains were cremated Gvt,11 (1 , 7OtL ?� 3'Ar1 (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 crp 1 p (9) Type of container in which remains were received and in which the remains were cremated 4rc7(L kri GoJ <it-t r Note: The Cremation Log shall be retained in the Permanent File of the Crematory