Delong, Scott @
Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: IS_VT . . ._ RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: .70-,- -
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
____ ' --__424A7
.__29A
NAME: C;7771.7 .4 CASE # -& '(
TYPE OF CONTAINE R:
PLACE OF DEATH: _C4,2.,5 - /A_ /$90,1/ 7_4:4_7e:e2.
ESTIMATED WEIGHT OF REMAINS & CONTAINER /__ __ _5
PLACED IN IN HOLD:
PLACED IN REFRIGERATION:
_
pi),2_-2_DATE OF CREMATION:
m1-0,TIME _.....-STARTED: _70- _ _ TIME COMPLETED:
PLACED IN RETORT: 4— __ _ _ MOVED: gg. - gi-29- - - 41,'
is.- _____
RETORT It IN WHICH REMAINS WERE CREMATED: Poo)er pekv--
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
04/28/2022 14: 31 5185487608 BOARD OF SUPERVISORS PAGE 01/09
New York State
NEW YORK Division of Department of
State
STATE OF
CEMETERIES
OPPORTUNITY Cemeteries 9gWashingtonne veue
Albany,NY 12231-0001
Telephone;(516)47V8226
www.dos.ny.yov
Authorization for Cremation and Disposition
This Authorization Form must be completed and signed prior to delivery of remains for cremation.
Date: 4/27/22 Number /A 3 Zi
Crematory Name: Pine View Crematory
Quaker Rd.,Queansbury, 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.
OPE_N.INO 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
Name of Deceased: Soon Datong
Marital Status' Never Married
Last Known Address: 1032 Bia_Brook Rd..(Man lake.NY 12842
Place of Death: Glens Falls Hosoltal.100 Park$t.,Glens Falls,NY 12801
SOX; Om OF Age. 83 DOB: Apprd1gra Date of Death: z 911-4.12c7.. Estimated Weight. 130
Description of casket/container in which remains will be delivered.
M�a C 1);111C C'Q vr4f1 = -r' lgt 5is r rr vylccE L n'ln 1.Y►[r
PERSON IN CONTROL OF DISPOSITION
(Person(s)In contra of disposition,in/tlel ONE of the following)
I amlWe are the designated agent of the deceased designated in a will or written instrument executed pursuant to Public
Health = Section 4201,
A` I/We have no knowledge that the deceased executed a written instrument pursuant to Public Health Law Section 4,201 or a
w aining directions for the disposition of his or her remains and Uwe 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:
Scott DeLong
(Nqr orDecM.A0)
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Authorization Cremation and Disp
osition
(Insert from the list below) ,,�� }}
Number:_ Description:,.3L, [V1
tel-maip e —jell_I(' )
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;
8. A lawfully appointed guardian;
7. Any person(s)eighteen years of age or older entitled to share in the estate and who is/are closest in relationship to the deceased;
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 Surrogates 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).
•._r • THREE of the following)
I
. 'I� INVe hereby affirm that the body of the deceased does not contain a battery, batte pack,ry pa , power cell,radioactive implant,
irii,
or radioactive device and that any such materials were removed prior to the execution of this Authorfzaffon Form. Failure to remove
t -Items prior to cremation may result in harm to the crematory and crematory personnel.
i, I/We affirm that instructions have been given to Patricia Miller
(funeret oh.eiv Nerre)
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
Mremeloy Namr)
is not responsible for the removal of personal items from the container or from the remains of the deceased. Personal items left in the
ilr or with the remains will be destroyed by the cremation process and cannot be retrieved after cremation.
IIWe hereby authorize Pine View Crematory
(Cnem.tory Name)
to cremate the remains of the deceased,
(Initial OPTIONAL)
IMre 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 DISPOSITION
The person authorized to receive the cremated remains of the deceased from the crematory is:
Miller Funeral Home
Name:
6357 NYS Rte. 30, Indian Lake, NY 12842 518.648-0011
Address: Phone:
The cremated remains of deceased will be disposed of as follows.
"."*�._tto tamiiy
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
ICmmoc y nkme0
the remains to Miller Funeral Home
fnins el Ibm*Name)
by delivery
in person or by registered mail. Scott Delong
(None erDereseed)
DOS-1898-f(Rev,04/20) Page 2 of 3
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Authorization for Cremation and Disposition
Ii
e following)
1
-1�� .I/We understand that if the remains are not claimed within 120 days of cremation,
1r-w Crematory
may dispose of the remains in
(Army or CremNoy)
an irretrievable manner,such as by scattering.
CREMATION CONT NER,URN
&Otis/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,
..., LI
C,• An urn is not yet purchased. UWe understand
d that if no urn is purchased or otherwise provided
• Crematory
will place the cremated remains in
INSnse a/cawyroron9
a rigid temporary container for delivery.
This Authorization Form was provided by Patricia Miller
was executed at
rFtelenit Di»ctar Narrer)
Miller Funeral Home
6357 NYS Rte.30, Indian Lake, NY 12842 (Fez errr,Marne Name)
(Funs.)Name 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 parson(s)identified below is/meth.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 Auth• if ion Form and au •rize(s)the foregoing.
Signed this 27 day of Aprd ,20 Z2 _
Ashley Delong r �� 44
rypad or POnted Nano SgrMtwe
PO Box 75,Speculator,NY 12184 ,
Address
types o•Ainted Nam, ivpnetwo
Mel's,
Typal or Printed Nang
Srpnrdrim
•rgeee
WITNESS:
Pnhirtiu Miller 4:1;ing40.0\i,"
Muttons:0 eetor Typed or Ainted tyome)
/FunaRN Dleeeor sgnsMr)12465
ramstren writs►)
Scott a nq
'Nemo orOsedoddd)
0OS-1898-f(Rev. 0420) Page 3 of 3