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Ellsworth, Betty L LF) Pine Vievv Cemetery & Cremnat«»rUUmm Quaker Road Qu«yvensbury' NY 12804 (51 8) 745-4477 or (51 8) 745^4476 FUNERAL HOME: _ °t....... ' -_ RETUQN T|K0E: DATE & TIME REMAINS ARRIVED AT CQsKxxJOIJy | / NAME OF FUNERAL DIRECTOR OR REGa|3TEREo RESIDENT DELIVERING vsnwc nsxxmmS: ............. k�r �o _. _� - -_-__-_-_......... N4K8G: - ---- TYpEOP COmT4/mER: ____ PLACE OF DEATH; ���� ^ h ----� -- -- -�'�]�0 _-_/]i���� � 7 " �-'--,'^~--^'=�1- ..... ...... ---- .......... _-------__-__-_-_-_-__-- ..........---...........-.... ..... .................... - '' ........_ ........... �- -_ L-.ST\K8ATE-0 Vvc-IGHT OF REMAINS & CONTAINER__ PLACED IN HOLD. ...............______ PLACED IN REFRIGERATION, DATE OF CREMATION: ................ _...... _________ TIME STARTED: ..... ................._TIME COMPLETED: pLAosm IN RE TORT, ______»« � nErVmT it IN vvn|Cn msxxAIms WERE CREMATED: DETAILED REASON FOR DELAY IF REMAINS vvE>\E CREMATED MORE THAN 40 HOUR FROM TIME Or ACCEPTED DELIVERY: --_-_--_______--_-_-------�-....... ................_-__ ............. _-_----___---_-__--_- _ ' NOTE: THE CREMATION Los onuLL BE nsrmwco IN rnc rcnmAwcmr FILE OF THE oncmA/onv. New York State Department of State i.....,r1NEW YORK Division of DIVISION OF CEMETERIES STATE OF One Commerce Plaza OPPORTUNITY.. Cemeteries 99 Washington Avenue Albany,NY 12231-0001 Telephone:(518)474-6226 www.dos.ny.gov Authorization for Cremation and Disposition This Authorization Form must be completed and signed prior to delivery of remains for cremation. 3/31/22 Date: Number: Z Z Crematory Name: Pine View Crematory Quaker Rd, Queensbury, NY 12804 518-745-4477 Address: Phone: 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 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 Betty L. Ellsworth Widow Name of Deceased: Marital Status: Hudson Park Rehab and Nursing Facility, 325 Northern Blvd.,Albany, NY 12204 Last Known Address: residence Place of Death: Sex: ©M Q F Age:92 DOB: 5/24/29 Date of Death:3/31/22 Estimated Weight: 140 Description of casket/container in which remains will be delivered. McDonald basic cremation container, no interior 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. O� l y I/We 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 I/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. My/Our relationship to the deceased is as follows: Betty L. Ellsworth (Name of Deceased) DOS-1898-f(Rev. 04/20) Page 1 of 3 Authorization for Cremation and Disposition (Initial the following) � ' I/We understand that if the remains are not claimed within 120 days of cremation, Pine View Crematory may dispose of the remains in (Name of Crematory) 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. -OR- \ t,\r\j Y 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 Crematory) a rigid temporary container for delivery. Patricia Miller This Authorization Form was provided by was executed at (Funeral Director Name) Brewer Funeral Home, Inc. (Funeral Home Name) 24 Church St., Lake Luzerne, NY 12846 (Funeral Home Address) 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. 31 March 22 Signed this day of , 20 Roberta Vanderzee Typed or Printed Name gnature PO Box 386, Lake Luzerne, NY 12846 Address Typed or Printed Name Signature Address Typed or Printed Name Signature Address WITNESS: Patricia Miller 4 (SYLI (Funeral Director Typed or Printed Name) �c.l Q Funeral Director Signature) 12465 (Registration Number) Betty L. Ellsworth (Name of Deceased) DOS-1898-f(Rev. 04/20) Page 3 of 3