Martino, Frank Jr. LF
Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: - 1� ,((,u� �,---- _ _____ RETURN TIME: 4,5Prp
DATE & TIME REMAINS ARRIVED AT CREMATORY: ___
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
NAME: fel ►A19km1� ----CASE #
TYPE OF CONTAINER:
PLACE OF DEATH; _-11110 Rwie _4J`rIkAix ICI
I
a 7o
ESTIMATED WEIGHT OF REMAINS & CONTAINER _--- /50gS- i
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION: L1/7011.1_TIME STARTED: _- J!10f%11 TIME COMPLETED: .5�fl1
PLACED IN RETORT: if• MOVED: I Z Q0 '.;ODftj
RETORT # IN WHICH REMAINS WERE CREMATED: f41(
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SHALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
A
New York State
D
tate
rtment�NEWYORK Division of DMSION OF CEMETERIES
STATE OF One Commerce Plaza
L1 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.
Date: '7 1 10 112 Number. 3 33
Crematory Name:Pine View Crematory v
Address: Zi OW I�itLR aof OveEk ei kJ f lOy Phone: (54 /`fc`4J'
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 everyttdng except bone and metal,
which are an 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 Army be left behind. The crematory we 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 NQ�s� vni r-H.�(�
Name of Deceased: )--Au lk in/Ali: N�� Cr Marital Status: '3i N97.
Last Known Address: II OS iC r9 <)c h fr t' A f' 4— r o o
Place of Death: 112 V 5 k*.f A IQ /a cr)O
Sear VM ❑F Age: o a DOB:C3`0751/y'ci.2 Date of Death: Q y`I8/ a- Estimated Weight !O
Description of casketicontainer in which remains will be delivered.
PERSON IN CONTROL OF DISPOSITION
(Person(s)in control of lisp ' initial ONE of the following)
are the ignated o d will or nt to fie
Health Section 4201.
-OR-
v 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 Ifwe 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:
mama orDersasecti
DOS-1898-f(Rev.08115) Page 1 of 3
Authorization for Cremation and Disposition
(Insert from the list below) ,/
Number: Description: /V t-I}Eti' g¢air (Pl l'P✓i‘P 7
1. A person designated in writing pursuant to Public Health Law Section 4201(3);
2. The surviving spouse;
2a. The surviving domestic partner,
3. My surviving child eighteen years of age or older;
4. A surviving parent
5. A surviving sibling eighteen years of age or older;
tA lawfully appointed guardian;
Any persons)eighteen years of age or older entitled to share in the estate and who is/are closest in relationship to the deceased; _
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. My other person who is acting on behalf of the deceased and who has exec uted a written statement pursuant to Public Health
Law Section 4201(7).
(In ��ALL THREE of the following)
lPWe hereby affirm that the body of the deceased does not contain a ery,battery pack,power cell,radioactive implant,
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. /
16 I/iNe affirm that instructions have been given to 437Ait: r �`I
/y
(FemeraiOueclorMsm)
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
(Crematory Name)
is not responsible for the removal of 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.
CO I—C. uve hereby authorize Pine View Crematory
(Crematory Marne)
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:My 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:
F/c r ei;a- CP• Wit &I>• Crr1-mA7►01; 0/j;7 P.o'es_ A;P
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
the remains to Edward L Kelly Funeral Home by delivery
(Funeral Home Mama)
in person or by registered mail.
riaLiC M ilif77l'� y1 r
(Name aoeaesecp
DOS-1898-f(Rev.08/15) Page 2 of 3
Authorization for Cremation and Disposition
(Initialt the following)
ia/
t'"' ' 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 any)
an irretrievable manner,such as by scattering.
CREMATION CONTAINERIURN
(Initial ONE of the following)
to be,tlyiteras a bine; the �;m�ir�has bed pure aced f Ed meml Home
and is cribed a lows:
WUe understand that if the urn is too small to hold the entire cremated remains,an additional rigid container may be used for delivery.
-OR14—
Ci An um is not yet purchased. i/We understand that if no urn is purchased or otherwise provided
Rue (�!t-4.) e re& A will place the cremated remains in
Name olCrematory)
a rigid temporary container for delivery.
This Authorization Form was provided by +-- ,41 '(2 ( 7 was executed at
CaeebrAamel
Edward L Kelly Funeral Home
Foam)Home Name)
1019 US Rt 9, PO Box 548 Schroon Lake.NY 12870
(Funeral Home Address)
and is signed by the funeral director as witness to its execution.
WYe have received a completed copy of this Authorization Form.
The person(s)identified below islare 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 day of ��j)r J/ ,20 oc
i)i ►.S Ca 1 l ? N S
Cj- 4
Typed or mono Name
76 tic gT 9 SGjn17- Ill L,044,, I= ' • l Z65'70
Addeas
Typed orPrrled Nemo
Addams
Typed or Printed Name Sifinable
Address
WITN
ihirr
A < a -
(Name arDecessed)
DOS-1898-f(Rev.08/15) Page 3 of 3