Strunk, Christopher E EL(
Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: RETURN TIME: lOONE
DATE & TIME REMAINS ARRIVED AT CREMATORY: s"5 I ZZ I2%ys
rl
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
NAME: --- 41e1.,s b_p 5T Rua- - -- - ---CASE #
TYPE OF CONTAINER: - - �� ..--1P^' 51 "_ --r`' -'`'_QtJ -
PLACE OF DEATH: ___... ! 1 I--- h1Y�� y�. - _..GRID.-_LIi M PSI12 -
ESTIMATED WEIGHT OF REMAINS & CONTAINER___._...._.. - - - _f&Q --� _J 234. sec lid
PLACED IN HOLD:
PLACED IN REFRIGERATION: __- (1;C Pr,
DATE OF CREMATION: J]0l2Z
TIME STARTED: _--_-_ /-_I1) Att TIME COMPLETED: _-_-_- 2•3S rt
PLACED IN RETORT: _ ��._�5 _ _ MOVED: J 40.1111
1 -
RETORT # IN WHICH REMAINS WERE CREMATED: _ SvKiL l‘ke
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
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New York Stole
erfNEW YORK Division of �SIDepartment ITIR�a
STATE OF
OPPORTUNITY_ Cemeteries 9Ong0 Woshihinngtnn ton Avenue
Albony,NY 12 2 31-0 001
Telephone:(t 1a)474-6226
www.dos.ny,gov
Authorization for Cremation and Disposition
This AuNrorttetIon Form must be completed end signed prior to delivery of remains for cremation.
5/t3/22 3 g 1
Datee; Number: Jp
Crematory Name:Pine View Crematory
Quaker Rd.Oueen,bury,NY 12804 518-745-4477
Address: Phone.
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation is carded 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 matenat from the cremation
chamber,but some minimal dust and residue will likely be loft behind. The crematory wig separate incidental end 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 pulverised until no
single fragment is recognizable as skeletal tissue.
9P NII4G OF THE COARAINER
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 era delivered In a container which is not suitable for cremation such as ceremonial or rental casket,the
crematory*Al 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 wel be conducted before a witness and will be done in privacy,with dignity and respect.
f DENTIJIcATION OF DECEASED
Christopher E.Strunk Divorced
Name of Deceased: _..._._..._........_ ....._. —..._ _.... Marital Status:........._._,.._• _..,
141 Harris Ave.,Lake Lucerne,NY 12848
Last Known Address:
residence
Place of Death:
75 1/23/1947 513/22
Sex: M ❑F Age: DOB: Date of Death: Estimated Weight: 150
Description of ceskot/orintainer in which remains wilt be delivered.
McDonald basic cremation container, no interior
PERSON IN CONTROL OF DISPOSITION
(Per eon(s)In control of disposition,in /ONE of the following)
_._.•.-_._— I am ve are the designated agent of the deceased designated in a will or written instrument executed pursuant to Public
Health Law Section 4201.
-OR-
R4 Uwe have no knowledge that the deceased executed a written instrument pursuant to Public Heutth Law Section 4201 or
wilt containing directions for the disprleitinn at his cx her remains end 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. Yy/Our relationship to the deceased Is as
follows:
Christopher E. Strunk
?iJarr i,i 0�oye�rJ1
DOS-1808-f(Roe.04/20) Pogo 1 of 3
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Authorization for Cremation and Disposition
(Insert frorry the fist below) fanner wits
Number: Description:
1, A person designated in writing pursuant to Public Health Law Section 4201(3):
2. The surviving spouse:
2a. The surviving dnmeetic pnrtnar,
3. My surviving child eighteen years of age or older•,
4. A surviving parent;
tf. A surviving sibling eighteen years of age or older;
6. A lawfully appointed guardian:
7. Any person(9)eighteen years of age or older entitled to share in the estate and who is/are closest In relationship to the deceased;
S. 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 or the deceased end who has executed a written statement pursuant to Public Health
Law Section 4201(7).
(In/Ue(ALL THREE of the following)
leNe hereby affirm that the body of the deceased does not contain a battery,battery pack,power cell,radioactive implant.
er radioactive device and that any such materials were removed tutor to the execution of this Authortaadan Form. Failure to remove
these items prior to cremation may result In harm to the crematory and crematory personnel.
Patricia Miser
. �,. IANe affirm that instruatione have been given to
(Amaral areatn,Namq)
regarding the removal of any personal pmporty or other thing of value which any person signing below or any family member of the
Pine View Crematory
deceased wishes to preserve.
fveirerey NwIe
is not responsible for the removal of personal Items from the container or from the remains of the deceased. Personal hems left In the
container or with the remains will be destroyed by the cremation process and cannot be retrieved after cremation,
S Pine View Crematory
Me hereby authorize
(C/MNNwy Burp)
to cremate the remains of the deceased.
(MIN OPTIONAL)
Uwe hereby authorize the named funeral director to provide for delivery to and cremation by en alternate
crematory.if deemed necessary In the opinion of the funeral dinner,and to amend this form to provide the correct name and
address of such alternate crematory.
Ftt!AL oisPoornoN
The person authorized to receive the cremated remains of the deceased from the crematory is:
Brower Funeral Home.Inc.
Name:
24 Church St..Lake Luzeme,NY 121146 618-696-2744
Address: Phone:
The cremated remains of deceased wilt be disposed of es follows;
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
(O*mmrtbfy Marital
the remains to Brewer Funeral Home.inc. _ by delivery
In person or by registered mall, u'iristopher E. Strunk
.........................
(Nowa of DIPK1414141
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Authorization for Cremation and-Disposition
(1a ia!the following)
Sr . IrWe understand that it the remains are not claimed within 120 days nt cremation,
Pine View Crematory
may dispose of the remains in
Kin*a crlwnafo )
en irretrievable manner,such as by scattering.
CREMATION CONTAINER/URN
(Initial ONE at the fallowktg)
An urn to be used as a contain*:for the cremated remains nee bean 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-
�� 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
rNerM of Cnmrarary)
a rigid temporary container for delivery.
This Authorization Form was provided by.,,_........_.._,.- was executed at
(1Vw ma are:Hung)
Brewer Funeral Home, Inc.
(Funeral liner Noel
24 Church SL,Lake Luzern,NY 12846
(Fun**Noma Addr►ry
and la signed by the funeral director as witness to Its execution.
i/We have received a tx)lnpleted copy of this Auihorizatfon Form.
The person(s)identified below Is/are the persen(a)In control of disposition,who by signing this Authorization Form,attests)
to the accuracy and completeness of the Information contained in this Authorization Form and authorises)the foregoing,
8 May 22
Signed this day of ,20
Svedana Recio Ip/*6na Vve � i. f� je(tJ -)
66 Hillside Ave.,Apt 2F,Now Vol*.NY 10040
4E4Wtt
r.►r.d a Frail urns 940411,0,0
Rai. �._.,...... ..-,.,,,,,,,,,,,,,,,,,,..,,.,,.,,.,,..,.,..,....,......_,.,....,......,..... _ _....,_�._..
1 rood or Aimed Nome Urtskur
Arnhem
WITNESS:
Patricia Miller \Ratc.AAsiAtivio
rime*i7MCtor rypw m Frrrnd Nan*) tFanarol L cfr Sipnatur+)
12465
(ffosbh*flon mow
Christopher C. Strunk
(NatM Of p.c.as0
003-1888-f(Rev.04/20) Page 3 of 3