Card, Elaine F 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; 3i11Zl
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
• ...
NAME: (1.-cA)E.. rhg•-0 CASE #
TYPE OF CONTAINER: rCvtit
PLACE OF DEATH: Ettu.6-414,_. 11-11)rici( E10410-0(i-cf!, irg9
_ .
_..... .
ESTIMATED WEIGHT OF REMAINS & CONTAINER /00 li,v
...
PLACED IN HOLD: /1,(G-/ 11
_....
PLACED IN REFRIGERATION:
DATE OF CREMATION: 3 Ito n . .
TIME STARTED: q.251301 TIME COMPLETED: //:00 till
PLACED IN RETORT: q;)o MOVED: hay. _ID-Li ott-7
RETORT /I IN WHICH REMAINS WERE CREMATED: TAki
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 40 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SHALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
New York State
NEW YORK Division of Department OF CEMETERIES
STATE OF DnnSION OF CEMETERIES
OPPORTUNITY.. One Commerce Plaza
Cemeteries 99 Washington Avenue
Albany,NY 12231-0001
Telephone:(518)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: 311 17 Z Number. Z Z 0
•
Crematory Name:Pine View Crematory Address: 21 Q✓'V vicji portp rdieck4.513017 pi t ( Phone: /�5113) 7tIC-0 I)
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
clamber,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: � /,t.1 E j. (E.'�A it rd. Marital Status: it.)I'd cr-"-6.
Last Known Address: 36. y ' i_-s (i." cZ t it cY-Lai v d s t, i yr / F 3
Place of Death:
��F/,.24..L o 4(C;,;i• iI.sii,%,i/ S �ixa 6._% T . /L y i ):s yr
Sent ElM tVF Age: h t7 DOB:a/- a b'- I IS�- Date of Death 03 -O 7- 0.2 Estimated Weight 1 0/0
Description of casket/container in which remains will be delivered.
fCli-er;C-e. et-enA77o(..., (,0 F.-7 n i L'e e- -- Cc,al k)04 ai
PERSON IN CONTROL OF DISPOSmON
(Person(s)in control of disposition,initial ONE of the following)
I e are tg sea s d.d f the decea r ---in a will or written inshumertt executed pursuant to Public
He h Law on 4201.
0 -OR- U
ti
UWe 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 Uwe 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:
cc-14/0,2- F. .1--1i-
(Name of
DOS-1898-f(Rev.08/15) Page 1 of 3
Authorization for Cremation and Disposition
(Insert from the list below)
r
Number: Description: .'C.'r ai:,;H_l d r Vgij£-1---
1. A person designated in writing pursuant to Public Health
ttLaw 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 fallowing)
t(� Y&V IIWe hereby affirm that the body of the deceased does not contain a battery,battery pack,power cell,radioactive implant,
( i/
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.�
04 (^ W li IIWe affirm that instructions have been given to . Cr�1 k.' , 7'� '\r--I
(F
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. Pine View Crematory
is not responsible for the removal of (Crematory Name)
po 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.
(Lk Liff J I/We hereby authorize Pine View Crematory
peasatoryName)
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:
r(-C`ro To Co , .--rii u V 1/JIVVVI-- -
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 Edward L Kelly Funeral Home by delivery
(Four Home Name)
in person or by registered mail.
e71). /,CI e_ l' /41-4
(Name aaeceased)
DOS-1898-f(Rev.08115) Page 2 of 3
Authorization for Cremation and Disposition
(Initial nth/e following)
61'''‘
/1,1 I,M U l/We understand that if the remains are not claimed within 120 days of cremation,
i Pine View Crematory
Warmors may dispose of the remains in
an irretrievable manner,such as by scattering.
CREMATION CONTAINER/URN
(Initial ONE of the following)
to be as acontainer fo th ated iris-Ft bens en purch: -�i from rd, j e
and is es bed as follows: % v
ilWe un rand that if the urn is too small hold the entire cremated remains,an additional rigid container may be used for delivery.
-, -OR-
A/ ) c 4 ,A1 An urn is not yet purchased. UWe understand that if no urn is purchased or othew se provided
1
�Cc will place the cremated remains in
(Nemo Crematory)
a rigid temporary container for delivery. , //
This Authorization Form was provided by -G•( Q /X-) -=� " t'"-/ was executed at
« � /
Edward L Kelly Funeral Home
Funeral
1019 US Rt 9,PO Box 548 Schroon Lake,NY 12870 ' O Namey
remer&Home Addams)
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)
the accuracy l
andp completeness of the Information contained in this Authorization Form and authorizes)the foregoing.
(jgned this ' 1n day of hi a 1�-' !1 ,20 : _.
—4- Gonstorice M Vi iIioore.._ } m V i' -L-
Add Z7-7 o A -rr�!? 4d 6-reetlFiel r /�ii 050�f7
typo/orPdated Name s
ignanue
Address
Typed orPth7ed Nan,. Sanative
Address
A7/
—4—e AU •Z:- —4--- .
imr „.
,..01 Nuatbm)
G/,(4)4,z r Cil r
(Name elDeceased)
DOS-1898-f(Rev.08/15) Page 3 of 3