Been, Timothy E •
Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME:
43_ ` RETURN TIME:
DATE 8, TIME REMAINS ARRIVED AT CREMATORY: 7
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
— _P.M Mta ...
NAME: TZMot
( (3
S
..SASE # 5
TYPE OF CONTAINER: //
_-. n ertor
PLACE OF DEATH: S". p e
ESTIMATED WEIGHT OF REMAINS & CONTAINER 1_11I Lo,J
PLACED IN HOLD: 3 M
...__... _io. 1
PLACED IN REFRIGERATION:
DATE OF CREMATION:
TIME STARTED:
ZQ.. .._.__.._. TIME COMPLETED: Lpic
PLACED IN RETORT: ��77 3r1i1 MOVED: B: za i
RETORT # IN WHICH REMAINS WERE CREMATED: —
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SHALL GE RETAINED IN THE PERMANENT FILE OF THE CREMATORY,
...
Ntrw York State
Department of State
NEW YORK Division of DIVISION OF CEMETERIES
STATE OF Ore Commerce Pia:,
OPPORTUNITY. Cemeteries 95 Washingtor
Aibany, 122
31-000'Telephone (518j 474(321i)
wwv.dos ny
Authorization for Cremation and Disposition
This Authorization Form must be completed and signed prior to delivery of remains for cremation.
7/12/22 SI�
Date: Number
Pine View Crematory
Crematory Name: • --.------
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 I
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
Timothy E.Been Divorced
Name of Deceased: Mantel Status:
234 Lamplighter Acres,Fort Edward,NY 12828
Last Known Address:
566 Rowland St.Ext..Saratoga Springs,NY 12866
Place of Death:
58 1/4/1964
7/12/2022 160
Sex. ❑x M O F Age DOB:_ Date of Death: Estimated Weight:
Description of casket/crontainer 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.
R
d INVe have no knowledge that the deceased executed a written instrument pursuant to Public Health Law Section 4201 or a
1 containing directions for the disposition of his or her remains and I/we are the person(s)having pnonty 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:
Timothy E. Been
(Na,e of Deceased)
DOS-1898-f(Rev.04120) Page 1 of 3
o.,
Authorization for Cremation and Disposition
(Insert frogs the list below)
brother
Number: Description:.___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;
6. 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 Surrogate's 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).
bInitial ALL THREE of the following)
- - 611We hereby affirm that the body of the deceased does not contain a battery,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.
}�I/We affirm that instructions have been given to Patricia Miller
rrunerai Davao,nw.n<•r -...------__
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
is not responsible for the removal of personal items from the container or from the remains of the deceased. Personal items left in the
ntainer or with the remains will be destroyed by the cremation process and cannot be retrieved after cremation.
Pine View Crematory
t f,UWe hereby authorize
(cwmd,n,Na„M,
to cremate the remains of the deceased.
(Initial OPTIONAL)
Uwe 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:
Brewer Funeral Home,Inc.
Name:
24 Church St.,Lake Luzeme,NY 12846 518-696-2744
Address: Phone:
The cremated remains of deceased will be disposed of as follows:
burialinLi ern _ em _t_ry
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 Name)
Brewer Funeral Home,Inc.
the remains to ______._______._._.___ by delivery
)Funeral Homernel E.Been
in person or by registered mail. rr1U y
(Name of De xssed)
DOS-1898-f(Rev.04/20) Page 2 of 3
e
Authorization for Cremation and Disposition
(Initial the following)
�. I/We understand that if the remains are not claimed within 120 days of crernatioiii View Crematory
V_______._ __._ --- may dispose of the remains in
Name M(..rnnwl:,')•
an irretrievable manner,such as by scattenng.
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
R-c`I7
J An urn is not yet purchased. Me understand that it no urn is purchased or otherwise provided
ine View Crematory
___ _ ._.__. will place the cremated remains n
(Nartr of awoaiory)
a rigid temporary container for delivery.
Patricia Miller
This Authorization Form was provided by was executed at
r,unera Deadest Na.mei
Brewer Funeral Home, Inc.
(Funs/el home Name
24 Church St.,Lake Luzeme,NY 12846
if'wlera,home Addn sl -_-__—
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.
12 July 22
Signed this . day of ,20
John Been �2J
I,peO wwo Name Y+ ,+ (J ` `•'' __._._...._.
566 Rowland St.Sxt,Saratoga Springs.NY 12866
AdfLSSs
r;vwr a�F4yead Nwnn Svnna!ure
Adeeoza
i,,ed n"i,otwl Neme Sprtafure
A_bfta,
WITNESS:
Patricia Miller � \
FunwL D mayry'MOO ur Pn„ted Name, (Funeral D+rocw Scha m,
12465
Timothy E.Been
----
(Name of Deceesedl
DOS-1898-f(Rev 04120) Page 3 of 3