Colon, Roberto LF
Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (51 ) 745-4476
FUNERAL HOME: {
RETURN TIME:
DATE 8 TIMEQh
REMAINS ARRIVED AT CREMATOR
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT D
4l.IVLRING REMAINS:
. .........
NAME:
Q'10Q,r+0 Cob n
CASE OF
TYPE OF CONTAINER:
PLACE OF DEATH: GQy),S ........_-40Sci;')'(1`1
_ I
ESTIMATED WEIGHT OF REMAINS K, CONTAINE ...... .... .
ISM l�bs AsIoi )bs
PLACED IN HOLD: j))
.. .. .... ....
PLACED IN REFRIGERATION:
DATE OF CREMATION: —
.-........
TIME STARTED: .. .�/.3_P►� .-----_-----
TI F. COMPL_ETED ,3► sm
RETORT:PLACED IRETORT: �--
I..�� -Q-"" MOVED: J-;1SPm. QS
3
RI-7-FORT II IN W �
RICH REMAINS WERE CREMATE 1:
DE TAILED REASON FOR DELAY IF REMAINS WEF' �� _. ...
E CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SHALL ESL RETAINED IN I HE PERMANENT FILE OF THE CREMATORY.
t
r New York State
Department of State
E OF
DIVISION OF CEMETERIES
NEW YORK pivision of One Commerce Plaza
STAT
OPPORTUNITY_ Cem 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: 07/27/2022 Number:
Crematory Name:Pine View Crematory ��R) 745-4476
Address:Quaker Road, Queensbu , NY 12804
Phone:
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation is ec ed nt placing he flame.
remains Thethe heateceased and the container and flame will incinerate and consume everything except bone and metal,
they are subjected to intense heat and fla
which are all that will be left after cremation.
Following but some he crematory w l take reasonable efforts to remove all of the will likely be left behind. The crematory wall separate incidental nc dental and foreign material tion
from
the
s some minimalden al dust and residue
the remains and the incidental and placed
foreignedn mat container or urn. Cremated remains generally are pulverized until no mechanically
pulverized into small pieces and placed into a designated
single fragment is recognizable as skeletal tissue.
OPENING OF THE CONTAINER
,such as to confirm the
The crematory may onlyd open the re that
nr oholding the un-cremated human remains in limited material is enclosed which might injure employees ordamage he crematory property. If
idhumanentity remains a deceased delivered
ivor to ensure tort n for
,the
rema are de that theh in a cons be moved into a suntainer which is not itablecontainer abbefore it accepts the remains.nThe opental ing of a
crematory thel transfer
that mo remains
container or transferor removal of remains will be conducted before a witness and will be done in privacy,with dignity and respect.
IDENTIFICATION OF DECEASED Divorced
Name of Deceased:
Roberto Colon Marital Status:
Last Known Address:17 E. Sand Hill Drive , South Glens Falls , NY 12803
Place of Death:Glens Falls Hospital, Glens Falls New York
Sex: El ❑ F Age:
60 DOB: 05/10/1962 Date of Death: 07/23/2022 Estimated Weight: S�_.
Description of casket/container in which remains will be delivered.
Buffalo Casket Company
PERSON IN CONTROL OF DISPOSITION
(Person(s)in control of disposition, initial ONE of the following)
I amNVe are the designated agent of the deceased designated in a will or written instrument executed pursuant to Public
Health Law Section 4201.
-OR-
X _&,../11_ I/Wi haves he that the his orased executed a herr remains and VI/we are the person(s)having prioritten instrument pursuant to lic Health Law Section 4201 rity under Public Health Law or a
lcontaining4 nd haves for igh disposition of
Section 4201 and have the right to authorize cremation of the remains of the deceased. My/Our relationship to the deceased is as
follows: Roberto Colon
(Name o/Deceased)
Page 1 of 3
DOS-1898-f(Rev. 04/20)
Authorization for Cremation and Disposition
(Initial the following)
U` IlWe understand that if the remains are not claimed within 120 days of cremation,
Pine View Crematory may dispose of the remains in
(Name of Crematory)
an irretrievable manner,such as by scattering.
CREMATION CONTAINERIURN
(initial ONE of the following) Regan & Denny Funeral
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.
-OR-
U
/' A-) 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
(Name of Crematory)
a rigid temporary container for delivery.
This Authorization Form was provided by Mark J. DeSimone was executed at
(Funeral Director Name)
Regan & Denny Funeral Home
(Funeral Home Name)
94 Saratoga Avenue, South Glens Falls, NY 12803
(Funeral Home 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 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.
Signed this 27th day of July 20 22
Grisselle Nieves
2X/2
Typed or Printed Name Signature
134 Hudson Street, S. Glens Falls, NY 12803-
Address
Typed or Printed Name Signature
Address
Typed or Printed Name Signature
Address
WITNESS:
Mark J. DeSimone
(Funeral Director Typed or Printed Name) ( I D r Sig,:tura)
10919
(Registration Number)
Roberto Colon
pweromeceesso
Dos-1898-f(Rev. 04/20)
Authorization for Cremation and Disposition f'S7
(Insert from the list below)
Number: 5 Description:sibiling
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).
(Initial ALL THREE of the following)
I/We 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.
aN I/We affirm that instructions have been given to Mark J. DeSimone
(Funeral Director Name)
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.
I/We hereby authorize Pine View Crematory
(Crematory Name)
to cremate the remains of the deceased.
(Initial OPTIONAL)
I/we 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:
Name:Grisselle Nieves
Address: 134 Hudson Street, S. Glens Falls, NY 12803- Phone: (518) 793-4139
The cremated remains of deceased will be disposed of as follows:
Burial at Saratoga National Cemetery
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)
the remains to Regan & Denny Funeral Home by delivery
(Funeral Home Name)
in person or by registered mail. Roberto Colon
(Name of Deceased)
DOS-1898-f(Rev. 04/20) Page 2 of 3