Masters, Melanie A Pine View Cemetery 8. Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: teiCa,/Ser--
RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMA-TORY:
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDF:nil DELIVERING REMAINS:
01)
- "----
NAME: Re14.)11+re..
CASE it 5-12 TYPE OF CONTAINER:AreWE,&.a,rd
PLACE OF DEATH: 6 e Aiej, 5 gr„30-4/ -
zzge)
ESTIMATED WEIGHT OF REMAINS 8, CONTAINER
PL ACED IN HOLD:
PLACED IN REFRIGERATION: ,04"--
DATE OF CREMATION: 7/a7-2ja,t17-1,1---
TIME STARTED: ... ... TIME
COME _/(7,.2-011kr1
PLACED IN RE-T.012T: '.-) ,L4.;j1/4') MOVED: L41/4/11 VE 041_1_
RE rani 14 IN WHICH REMAINS WERE CREMATED: Pe-Atic.0
rAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NO TE: TFiE CREMATION LOG SHALL (Hz RLTAINFD IN THE PERMANENT FILE OF THE CREMATORY.
i ^ Y
NEW YORK New York State
Division of Department of State
STATE OF DIVISION OF CEMETERIES
OPPORTUNITY.. Cemeteries
One Commerce Plaza
99 Washington Avenue
Albany,NY 12231-0001
Telephone:(518)474-6226
Authorization for Cremation and Disposition www.dos.ny.gov
This Authorization Form must be completed and signed prior to delivery of remains for cremation.
Date: 07/24/2022 S Dn S
Number:
Crematory Name: Pine View Crematory
Address: 21 Quaker Rd., Queensbu , NY 12804
Phone: Sl4- NS- s(44?2
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.
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
Name of Deceased: Melanie A. Masters
Marital Status: Divorced
Last Known Address: 781 Wall St., Diamond Point, NY 12824
Place of Death: Glens Falls Hospital, 100 Park Street, Glens Falls, NY 12801
Sex: 0 M El F Age: 66 DOB: 11/21/1955 Date of Death: 07/22/2022 Estimated Weight: 150
Description of casket/container in which remains will be delivered.
New England Cremation-deluxe cremation container
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-
INVe have no knowledge that the deceased executed a written instrument pursuant to Public Health Law Section 4201 or a
wil contai ing directions for the disposition of his or her remains and I/we are the person(s)having priority under Public Health Law
Section 42 1 and have the right to authorize cremation of the remains of the deceased. My/Our relationship to the deceased is as
follows:
Melanie A. Masters
(Name of Deceased)
DOS-1898-f(Rev.04120) Page 1 of 3
Authorization for Cremation and Disposition
(Insert from the list below) p On
Number: 3 Description:Survivin Child
1. A person designated in writin
2. The surviving spouse; g pursuant to Public Health Law Section 4201(3);
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
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 4 0 (7) to the deceased;
10. A chief fiscal officer of a county or a public administrator appointed
10a. Any other person who is acting on behalf of the deceased and who has executed a written statement pursuant
hpas
tut the writteSurron
a Court Procedure Public;
Law Section 4201(7).
p ant to Health
(Initial A L THREE of the following)
II I/VVe hereby affirm that the body of the deceased does not contain a battery,
or radios•ive device and that any such materials were removed prior to the execution of this Authorization Form. Failure to remove
crematory
these items prior to cremation mayresult in harm to theand crematory personnel.
I/We affirm that instructions have been given to
David Alexander
regarding the removal of an (FuneralDirector Name)
y personal property or other thing of value which any person signing below or any family member of the
deceased wishes to preserve.
Pine View Cremator
y Name)
is not responsible for the removal of personal items from the container or frotm the remains of the deceased. Personal items left in th
container or with the remains will be destroyed by the cremation process and cannot be retrieved after cremation. e
I/VVe hereby authorize&lik.N,
Pine View Cremato
(Crematory Name)
(Initial OPTIONAL) to cremate the remains of the deceased.
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:Alexander-Baker Funeral Home, David Alexander
Address: 3809 Main Street, Warrensburg, NY 12885
Phone: (518) 623-2065
The cremated remains of deceased will be disposed of as follows:
Return to family
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 Alexander-Baker Funeral Home by delivery
(Funeral Home Name)
in person or by registered mail.
Melanie A. Masters
(Name of Deceased)
DOS-1898-f(Rev.04/20)
Page 2 of 3
•
4 ,
Authorization for Cremation and Disposition
(Initial the'following)
I/We understand that if the remains are not claimed within 120 days of cremation,
eitli
Pine View Crematory
(Name of Crematory) may dispose of the remains in
an irretrie ble manner, such as by scattering.
CREMATI f N CONTAINER/URN
(Initial ON: of the following)
Al An urn to be used as a container for the cremated remains has been purchased from Alenmcnder-Baker Funeral
I Ixa
and is de ribed as follows: Crescent Memory Chest
I/We under tand that if the urn is too small to hold the entire cremated remains, an additional rigid container may be used for delivery.
-OR-
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 David Alexander was executed at
(Funeral Director Name)
Alexander-Baker Funeral Home
(Funeral Home Name)
3809 Main Street, Warrensburg, NY 12885
(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,attests)
to the accuracy and completeness of the information contained in this Authorization Form and authorize(s)the foregoing.
Signed this 24th day of July ,20 22
Cira A. Masters
Typed or Printed Name Signature
1 Shire Lane, Burnt Hills, NY 12027
Address
Typed or Printed Name
Signature
Address
Typed or Printed Name Signature
Address
WITNESS:
David Alexander
(Funeral Director Typed or Printed Name) r n
10034
(Registration Number)
Melanie A. Masters
(Name of Deceased)
DOS-1898-f(Rev. 04/20) Page 3 of 3