Robtay, John Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: RETURN TIME:
DATE 8. TIME REMAINS ARRIVED Al CREMATORY: 71_2;c0117
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
EcL4 541vAALZ- OECiiotti _..
NAME: 3-041r3 Rogtokl
CASE It qiz
TYPE OF CONTAINER: (0 a 14i C‘,1'ilk V. ihec6/ 3egog
PI ACE OF DEATH: CLIAIZ fd :FE
Ef,TIMATED WEIGHT OF REMAINS 8, CONTAINER 170 5c tele
Pt ACED IN HOLD:
2 1
PLACED IN REFRIGERATION: ;4
_
DATE OF CREMATION: 11.
. _ .
TIME STARTED: ISAn TIME COMPLETED:
PLACED IN RETORT: g 001T MOVED: 611 ,01;_q_07
RETORT II IN WHICH REMAINS WERE CREMATED: fe;F r014;ER
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY-
NO rEE THE CREMATION LOG SHALL LH_ RETAINED IN THE PERMANENT FILE 01 THE CREMATORY.
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New York State
Department of State
DIVISION OF CEMETERIES
NEW YORK �IVIs10R of One Commerce Plaza
STATE OT 99 Washington Avenue
OPPORTUNITY. Cemeteries Albany. 61 n 31-0001
Avenu
Telephone:(618)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.
g( Number
177
Date:
Pine View Crematory
Crematory Name: (518)745 4477
Quaker Road,Queensbury.New York 12804
Phone:
Address:
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation is carried out by placing the remains of the deceased and the container holding the remains bone and metal,
into a cremation chamber where
they are subjected to intense heat and flame. The heat and flame will incinerate and consume everything except
which are all that will be left after cremation.
material
Following cremation,the crematory will take reasonable efforts to remove all of the remains and other er mati and foreign material from from the cremation
chamber,but some minimal dust and residue will likely be left behind. The crematory will separate remains will be in
the remains and the incidentalandnlaced9 to aterial will be designated container or urn.ed of as rired by law. The emated remains generally are pulverized until no mechanically
pulverized into small piecesP
I single fragment is recognizable as skeletal tissue.
OPENIN HEG OF T C ONTAINER
The crematory may only open the container holding the un-cremated human remains in limited circumstances,such as to confirm the
identity the deceased
deliv to ered
in a containeraterial is which is notno uitable for c which ht injure remation such ees or damage the crematory as ceremonial or rentalcasket,the If
humanremaremains are de with. dignity ing reaped.
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,
IDENTIFICATION OF DECEASED Marital Status:LJ 1 Ca('1�
Name of Deceased: A l t` rT 039
Last Known Address: - I 753'Z
Place of Death: �h
r) C> `5 l i° - Date of Death:[) L L -Estimated Weight:__-
Sex: �M ❑F Age: � 1 DOB:
Description of casket/container in which remains will be delivered.
Corrugated Cardboard Box with Plywood Starmark Model#38808
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.
-OR-
I/We have no knowledge that the deceased executed a written instrument pursuant to Public Health
L btSectionh 201 or a
w
will containing directions for the disposition of his or her remains and I/we are the persons)having p tY
under Section 4201 and have the right to authorize cremation of the remains of the deceased. My/Our relationship to the deceased is as
follows.
of Deceased)
Page 1 of 3
DOS-1898-f(Rev.04/20)
https://www.pdfrun.com/render/preview/2701878
Authorization for Cremation and Disposition
(Insert from the list below)
I AM THE ONLY SURVING CHLD
Number: 3 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).
(Initial ALL THREE of the following)
DMR 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.
Cassia Rafferty#14100
DM I/We affirm that instructions have been given to
(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.
DNR I/We hereby authorize Pine View Crematory
(Crematory Name)
to cremate the remains of the deceased.
(Initial OPTIONAL)
DMR 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:
REMAIN ARE TO BE RETURNED TO THE SURVNG DAUGHTER DAWN M ROBTOY
Return to family to ba 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. ---3ah \>--
Mamec1 Decamp
DOS-1898-f(Rev. 04/20) Page 2 of 3
Authorization for Cremation and Disposition
(Initial the following)
°MR
I/We 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 CONTAINER/URN
(Initial ONE of the following)
Baker Funeral Home
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-
DWR 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.
Cassia Rafferty#14100 was executed at
This Authorization Form was provided by
(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 F .
The person(s)identified below is/are the person(s)In control of disposition,who by signing this orization Form,attest(s)
to the accuracy and completeness of the information contain and autho (s)the foregoing.
Signed this a day of ,20
DAWN M ROBTOY
Typed or Printed Name Signature
1338 VILLINES AVE SAN JACINTO CA 92583
Address
Typed or Printed Name na u
Address
Typed or Printed Name Signature
Address
WITNESS:
Cassia Rafferty ��
�r(
(Funeral Director Typed or Printed Name) (Funeral Di or Signature)
Funeral Home Reg.#01130
(Registration Number) (Name of DOS-1898-f(Rev. 04/20) P46J h/i