Tucker, Ronald (L�F�
Pine view Cemetery & Gremnetorill-Irn
Quaker Road
Queensbury' NY 12804
(51 8) 745-4477 or (51 8) 745-4476
FUNERAL HOME:
RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREKx/\TORY/ —.-
NAMEoF FUNERAL DIRECTOR OR REomSTERr-n RESIDENT DELIVERING
REMAINS,
---------------_--�'m��__
���.......� � � ������. �`
NAME: �-----~----~° --' ....`...............-------__-__'CASE It
TYPEOPC0mT4ImER: _-
PLACE ' -' -
OF 0EJ�T��� �C1 _ /��
� ^ =____^--~ �%........EST!K8ATED WEIGHT OF REMAINS & CONTAINER
PLACED IN HOLD; _......
PLACED IN REFRIGERATION: ... ............_
DATE OF CREN1�\T|0N'
�/* |
.......
- ' -�` '-'-----------'----------- L/�^'
��
TIME STARTED: /'� T|Ms COMPLETED: �
pLaosn IN RETOR-r; ______««(}»s�` ..................... _....._
nerouT It IN vvMiCn REMAINS WERE CREMATED:
�DETAILED REASON RE4S{]N FOR DELAY IF REKn4\mS WERE CREMATED MORE THAN 48 HOUR
FROM TIME OF ACCEPTED DELIVERY:
----'--'----'-----------..... '`r-- .............----................. ---.............
---------------__-__- _
'
NOTE: THE cnswxT|Ow Los SHALL BE nc/mwco IN Tor- pcnmowcm/ FILE OF THE oncMATnn,.
1 p '1 n-^ !P South �
t �e'._", -'�� ��<_ " AM FCSB CId.rin��r. South EPJ �TC. P.
New York State
rriNEW YORK Division of DepartmentFM of State
TERRIES
SATE OF
nlVlslAN OF CEMETERIES
OPPORTUNITY_ Reza
One Commerce
Cemeteries 99 Washington Avenue
Albany,NY 12231.0001
Telephone;(518)47446226
www.dos.ny.gCv
Authorization for Cremation and Disposition
This Authoring/an Form must be completed and signed prior to delivery of remains for cremation.
bate:03/30/2022 Z
— w Number:
Crematory Name:Pins View Crematory
Address:Quaker Road,Queensbury,NY 12804 S18-745-4477
Phone:
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
i 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 end foreign material will be disposed of as required by law. The cremated remains will be mechanically;
pulverized into smell 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 coceased or to ensure that no material is enciosee 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 acne in privacy,with dignity and respect.,
IDENTIFICATION OF DECEASED
Name of Deceased:Ronald Tucker Marital Statue:Married
5'5
Last Known Address: 1 Lake Ave,Lake Lizerne,NY 12846
Place of Death:551 Lake Ave,Lake Luzerne,NY 12846
Sex: El ® F Age:62 arse:06/02/1955 Date at Death:03/29/2022 Estimated Weight igs(br
Description of casketicontainer in which remains will be delivered.
Minimum Cremation Casket- Florence Casket Co. Pine/Cardboard
PERSON IN CONTROL OF nisPOSmON
(i rsant's)in control of disposition,lintel ONE of the fo11owIng)
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.
-QR-
' ' 3 IIWe have no knowledge that the deceased executed a written instrument pursuant to Public Neeite Law Section 4201 or e
will containing directions for the disposition of his or her remains and ewe 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:
Ronald Tucker
— rrTu7ae:>IDerRasedJ
DOS-1898-f(Rev.04/20) Page 1 of 3
1 ; '' PCSB Clarinda South F 1.1 . • P. uS4
Authorization for Cremation and Disposition
(Insert from the list below)
Number; 2 Description:The skiviving spouse
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 end who isiere closest in relationship to the deceaeea;
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).
(Arafat ALL THREE of the following)
I/We hereby affirm that the body of the deceased does not contain a battery,battery pack,power cep,radioactive implant,
or radioactive device and that any such materials were removed prior to the execution of this Authorization Form. Failure to remove
these l ems prior to cremation may result in harm to the crematory end crematory personnel.
V� IIWe affirm that instructions have been given to Stephanie Gilman
Funeral Gfnurhr Arne)
receding the removal of any personal property or other thing of value which any person signing below or any family member of the
deceased wiehes to preserve. Pine View Crematory
(cenreive male
Is not responsible for the removal of personal Items from the container or from the remains of the ceceased. Personal items left in the
container or with the remains will be destroyed by the cremation process and cannot be retrieved after cremation.
9- - 11We hereby authorize Pine View Crematory — —
(Cannaer,Narre)
to cremate the remains of the deceased.
(Initial OPTIONAL)
_ 1/we hereby authorize the named funeral director to provide for delivery to and cremation by an alternate
crematory,if deemed necessary in the opinion of the funeral director,and to amend this form to provide the correct name and
address of such alternate crematory.
FINAL DISP9SITIt7N,
The person authorized to receive the cremated remains of the deceased from the crematory Is:
Name: M.S.Khmer Funeral Home
Address: 138 Main Street,South Glens Fells,NY 12803 Phone: 518-747-9266
The cremated remains of deceased will be disposed of as follows;
rdlven to Kenneth Tucker
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 Nam.)
the remains to M.B.Kilmer Funeral Home
—__-- by delivery
(Faneral Hans Nerve;
in person or by registered mall. Ronald Tucker
(Name of o.o.esaa] —
DQS-1898 f(Rev.04/20) Page 2 of 3
11 ,k, '0%%/WE= 11 7:h' A)1 PCSB Clarinda South EN , No,
Authorization for Cremation and Disposition
(Initial the following)
Wile understand that if the remains are not claimed within 120 days of cremation,
Pine View Crematory may dispose of the remains in
(Now orcremeiory)
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 descibed es follows:
I/We understand that if the urn is too smat to hold the entire cremated remains,en additional rigid container may be used for delivery,
-OR-
An urn Is not yet purchased. I/We understand that if no urn Is purchased or otherwise provided
Pine View Crematory will place the cremated remains in
(Name of cremetory)�—
a rigid temporary container for delivery.
This Authorization Form was provided by Stephanie Gilman was executed at
(Funarsi awaor Name)
M.B.Kilmer Funeral Horne
(Funeral Horne Nina)
136 Main Street,South Glens Falls, NY 12803
(Amara Name Addreaa)
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 Isiere 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 authorizer)the foregoing.
Signed this 30 day of March ,20 22
Mary Ann Tucker
7ypad cv Printed Name Signature
2379 P.Ave,Coin,IA 51636
Address —" -
Typed or Printed Neme Slaneirr&
Address
.Typed or Printed Mum signature
WITNESS:Stephanie Gilman 11.
' .C� -��-�
(Funeral Director 7)petl or Printed Noma) (Funer for etue)
14163
Ronald Tucker
(Mama atcocesaed)
DOS.1898 f(Roy.04/20) Page 3 of 3