Deyette, Judith Ann \OF
Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: wal RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: I Ill I it. (f'("MI
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
Nscq Ca PO ieo
NAME: 3°0LU 2 1 CASE # (AA
TYPE OF CONTAINER: Co a`7 1 a .it 540.4tc f i 3f$o$
PLACE OF DEATH: ptnr fills Hos )dal
ESTIMATED WEIGHT OF REMAINS & CONTAINER 146
PLACED IN HOLD:
PLACED IN REFRIGERATION: 11 isAll
DATE OF CREMATION: 8111)22
TIME STARTED: I'3C TY1 TIME COMPLETED: 2'SV-7
pp
PLACED IN RETORT: l )D T n MOVED: �`qo fh t Z'1�� 1 'Ll5ftl
RETORT # IN WHICH REMAINS WERE CREMATED: 'row ER_ '1 k
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.
I,
Authorization for Cremation and Disposition
(Insert from the list below)
Number: 6.3 Description: S(>n
1. A person designated in writing pursuant to Public Health Law Section 4201(3);
2. The surviving spouse;
2a. The surviving domestic partner;
® Any surviving child eighteen years of age or older;
4. A surviving parent;
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).
(Ini' 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.
I/We affirm that instructions have been given to Cassia Rafferty#14100
(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.
2>----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: Baker Funeral Home Personnel
Address: 11 Lafayette Street, Queensbury, New York 12804 Phone: (518)761-9303
The cremated remains of deceased will be disposed of as follows:
Return to family to be decided
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 Baker Funeral Home by delivery
(Funeral Home Name)
in person or by registered mail. 1 `Q
lei dCL.
(Name of Deceased)
DOS-1898-f(Rev.04/20) Page 2 of 3
t
Authorization for Cremation and Disposition
(Initial the following)
.,„Z: l/We understand that if the remains are not claimed within 120 days of cremation,
>_____
1 iLt \I1 t-lCC eXt-fnG-1 ovl A may dispose of the remains in
(Name of Crematory)
an irretrievable manner,such as by scattering.
CREMATION CONTAINER/URN
(Initial ONE of the following)
An urn to be used as a container for the cremated remains has been purchased from f -liyt r1 ytt-k_
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.
-O
An urn is not yet purchased. I/We understand that if no urn is purchased or otherwise provided
Pia 9 V I t w C 4CM.( will place the cremated remains in
(Name of Crematory)
a rigid temporary container for delivery.
This Authorization Form wasprovided byCassia Rafferty#14100
was executed at
(Funeral Director Name)
Baker Funeral Home
(Funeral Home Name)
11 Lafayette Street, Queensbury, New York 12804
(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 00 11 day of orj t' ,20 (d ), .C
ei eitg__ '
Typed or rin Name D re,
, C , V
Address
Typed or Printed Name Signature
Address
Typed or Printed Name Signature
Address
WITNESS:
Cassia Rafferty
(Funeral Director Typed or Printed Name) (Funeral Director Signatu
Funeral Home Reg.#01130
(Registration Number)
O
cAsyl _
(Name of Deceas
DOS-1898-f(Rev. 04/20) Page 3 of 3