Peckham, Shawn M (L DF
P�meV'evvCc-mmatery 8, GremmetoriLlmn
Quaker Road
Qmevensbury, NY 12804
/51 8\ '745-4477 or (51 8) 745-4476
17VNER4L MO01E:
�__.... ......._________ _ -- ,lETV11N T|k0E:
nATC- & TIME REMAINS ARRIVED Al' CRsxn/\T0BY/
m4x«E OF FUNERAL DIRECTOR on nEGR|STEuEo uE8-.u�wx �- s ����=- -
oELmEmmcncmA/wo
NAK0E: �u� ------ -
CASE
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TYPE OP COmTmmr--a _--�
/
PLACE OF DEATH: �m
----�-- /w�+
^/ t_... _'=�^__/z�m---�.l~_- /
.................... ..... ............. .............
L-.8T|K8ATr--D WEIGHT OF REMAINS 8 CON-r A/mF.R-_________7W0
PLACED IN +|/mLo:
PLACED IN REFRIGERATION:
nATE OF CREMATION: ---------�
-__' --___
TIME STARTED:
TIME COMPLETED:
pLxosm IN Rcrmnr� /
--^ ---___- .........
_»»p«s�� _
xeronT V /N vvM|CH vvsRE CREMATED:
DETAILED REASON FOR DELAY IF REMAINS WERE ^CREMATED »x0 'ETHAN 40 H|D--R
FR0KA T\MtZ OF ACCEPTED DELIVERY: _ ........................
_____
-_--_---'_-__----_-__-__- -- ...............--__--_...... ........_................_ ..............
_-_-_-__-'__ _
NOTE: rxs r1112-mxT|0w LOG SHALL BE ncTxwco IN Txc rcxmAwcwr FILE: OF /nc cncm«Tnn'.
•
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,-..New York Strste
Deparfine nt,00 State
Q r DIVISION OF CEMETERIES • y"
STATEOF One omrrierce Plaza ,
ffPPOR'IUNIT S� '89 W ton Avenue
Cemeteries ; ,Albany,Phi 12231-0001 •
Telephone;(518)474-S226 '°
' www.dos.ny.gov
Authorization for Cremation and Disposition
..,_ This 4uthorizatloh Form must be completed and signed prior to delivery of re�ma s fors emation. ,
Date: ` 6` 2�; Number: '�
Crematory Name:
Pine View Crematorium
Address:C Quaker Rd.,Queensbury,NY 12804 518 745 4477 .
t>otse
CREMATIOI AI -IRR�RSIBLE AND FINAL PROCESS .
Cremation is carried outbyt,placing the remains of the deceased and the container holding the remains into a cremation chamber where
theyare su ect dto intense heat and flame, The heat and Battle +IH Incl iterate end eonsumo hi exce Delta and'metal,
;�� bI � pt
which are all that will be left after cremation.
Following cre abon,the crematory will take reasonable efforts to remove all o
if the remains and other material from,the ration
chamber,but some minimal dust and residue will likely be left behind. The crematory will separate incidental and foreignrnaterial from
the retrains and the incidental and foreign material.will be disposed of as required by law. The cremated remains will ittrachanicailyr..
pulverized intt mall pi s and placed into a designated container or urn. Cremated remains generally are pulveri until no ',
single fragment ,recegn ble as skeletal tissue,.
OPENING CIF THE CONTAINER ` ,
The cremato y may only open the container holding the un-cremated hug*remains in limited circumstances,such an fuconfirm the
identity of a eeased'or to ensure that no material is enclosed whir h might"injure employees or damage the Creinat ' perti If „ .. _ ,'
human remains are deliverad in a container which is not suitable-for cremation such as c eremonialor rental casket,the
crematorywill " dire that the remains be rrieVed into a suitable container before it a is the remains.,'lase i i"ni
mR Epp ! a
container or the transfer or removal of rer aine;Wilt;be conducted before.a witness and will be done In privacy whit d nity ar free peg
IDENTIFICATION OF DECEASED, • . ,
Shawn M. 'ed h rn' Never tubed
NormsofLieceaseds - l Status .
last Known Address: 20 Geroge Street.Fort Ann,NY 12827
,,,_
Place of i lath 20 Geroge Street.Fort Ann,NY 12827 ,
49 12/1611980 e t,,„,„,t2022 .
se> # Vie;., gate of t �h ,�nt
,
gescnptign of aask/entainer in whreh remains will be delivered. F
Match s Cremation Case;'Cardboard Too,:Wood. ftom , '- Y
t�tl1� . a
P "PN .0 OL QP 9ISPOSITWN. a a , .W
.
t'"ems/s) i �i r Ispositton;initial taivE of.rho foNowlrrg)
,
I am We are the'designaten agent of the d ased designated in a WilierWriitten instrament exect# td pursuance Public'
Health Law;Sectiion 4201.
- . i/We have no knowledge that the deceased executed a wrtten instrument pursuant to�Public Health Law S uet 4: 1 or a�
Will cdetaigtng directions for the dispositionSedan
cremation of the rdmarnrs of the fi red; lour reiatlo hrip to .ceased is as
,,,•.a �
t it+ows ,..r. � b
haw!• S 10 P.ackham
vro
1 E3 f(Rev 04/30). l Page 1 trf"3 .
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for Cremation and DIspos1 `r 7
zion
' art from the4sttietobv)
tVumber `:... Description.Friend ,
• 1 A person designated in writing pursuant to Public Health Law Section 4201(3), 1r°
2, . The surviving spouse:
2a, 'he surviving doi'nestic partner,
3,' My surviving child eighteen years of age or older,
4. 'A Surviving parent;: "�
S. A surviving sibling eighteen years of age or older: •
• . 8. , ;A lawfully appointed guardian; .
-1, ' Any person(s)eighteen years of age or older entitled to share in the estate and who#stare closest in relationship to the.deceased: a ,-,
8. A duly appointed fiduciary of the estate; t'
9. A close friend or relative who has executed a written statement pursuant to Public Health Law Section 42O1(7 , , `,.; "
10.. A chief fiscal officer of a county or a public administrator appointed pursuant to the Surrogates Courf I'rooedtare Act
10a. Any other person who is acting on behalf of the deceased and who has,exerted a written s iterrient pursuant is"Pl c l"ieafh 4 ,,
... Law Section 4201(7). „ ..
( pJ AL€F7ftftEE of the following)
,
tie hereby affirm thatttla.body'of the,d ::aced does hot ntairi a bs ttety,baited ., •,,, vet-�,ra
or radioactive device and that any such materials were removed prior to the execution of this Authorization Form. Failure to remove
these items:priorta cremation may result icf,harm to the crematory and crematory personnel., ,,;,;,
ei N#ttA7e ed/rip that instructions have been given to
Lance Evans
regarding the removal ef any Peratmetproperty or other thing of value which any person`signing below or any'famliy melltbor t ry 1`* ":
Pine View Crematorium
deceased wishes to preserve.. , y
( + runt �. s
is not responsible for the removal of personal items from the container or from the remains„of the deceased,„Personal.ltms let ht the,
itainer or wits the remains will be destroYed by the cremation Macias and cannot be retrieved after cretrtatlork . ,,
l herebyauttioriim Pine View rentatonum•• .
tcnx n�axy rr `: m
to cremate the renaieivitelcseo. . '...
Of**
' Itwe hereby authorize the named funeral director to provide for delivery to and cremation by,an alternate
crematory;if'deemed da sar)'in the optnlo i of Otte funeral director,and to amend"this I rm try provi a the Corr name and
a ddreet of h ems alto
�. .,,: ., Sim � !t',.
v.
FINAL PtSPO 11'If - F
't perspa . zed to rece tho cremated remains of the`deceased from the,cremate is �
Carleton Ffinerai-Home,inc.
Kama., )
ss 88 Main St Hudson Falls New York 1289 tdde Phoneeb1 dTtT4� 0
ddd � '74 fl ` ' "..•' t creme finan f decea l rspr as olows fi � <, ''v. ,
'p' a _•4 >R tr 3family' ,, �; E
ifforany reason the person named above does not take possession of the cremated remains • a
Pine thew Crematorium
. f m�miyNimo is rthortz tit give p s #ion elf
ererrtains to Carleton Funeral Herta,'Inc.,,,,,,-',,
(F!)0401,41 met -, day ,cte'''.'" y
, In person or by isft red mail S .
• haven M pgckham ` � ���'
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