Cerrone, Virginia L LF
Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: Ktttl RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: 8 iv Z 12.3o-fh
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
'Tp�� �k,co.t
NAME: if�(� N (tee°a-)E. CASE # 0
TYPE OF CONTAINER: F') 4 ((7 fit irmor' UNT
PLACE OF DEATH: (IS u�QI I�'I
ESTIMATED WEIGHT OF REMAINS & CONTAINER 2SD 4., I 760
PLACED IN HOLD: p�,,
PLACED IN REFRIGERATION: j2. 1 t 1
DATE OF CREMATION: fI30I LZ
TIME STARTED: 7`'1-I191gYI TIME COMPLETED: Jro'3
PLACED IN RETORT: g d S�� MOVED: S'SS fitl i;i cel Holt,
RETORT# IN WHICH REMAINS WERE CREMATED: lJJ /' j
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.
New York State
Division ofDepartment OF CEMETERIES
State
NEW YORK DIVISION OF CEMETERIES
STATE OF One Commerce Plaza
OPPORTUNITY..
POR1UNITY Cemeteries 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: g I lq l lZ Number.
Crematory Name:Pine View Crematory
Address: 2 l G,ilsogz A-fl 0o @J R,/ - 12t Phone: 15itO )`I c
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
clamber,but some minimal dust and residue will ilkely be kilt 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: Vl t-71 u; A L ' c Marital Status: l0z-0 .2-d-
Last Known Address:' /V 9'- U 5 )1 / S',4, A - 1`�)( /L57a
Place of Death: (0/Ql.`S Ads f`ios -m/ Cjp w FA l�S ,uy, vizi of
Smc M jOilrF Age: TO DOB:9y/c/)9i A. Date of Death: O ff/Y?/2o _ Estimated Weights 6
Description of casket/container in which remains will be delivered.
Floc ea- go.n- cn eu 11 v it
PERgON IN CONTROL OF DISPOSITION
(Person(s)in control of disposlIfon,initial ONE of the Mowing)
a cited agent of the disci din ex nt to
Wile have no knowledge that the deceased executed a written instrument pursuant to Public Health Law Section 4201 or a
containing directions for the disposition of his or her remains and Uwe are the person(s)having priority 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: r' �p�l t3I A (NameDeceased)
DOS-1898-f(Rev.08/15) Page 1 of 3
r
Authorization for Cremation and Disposition
(Insert from the fist below)
Number. 3 Description: SI n
1. A person designated in writing pursuant to Public Health Law Section 4201(3);
2. The surviving spouse;
2a. The surviving domestic partner;
3. My 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. My 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).
(InIal •, of the following)
�...1 IIWe hereby affirm that the body of the deceaseddoes not contain a battery,battery pack,power cell,radioactive implant,
as,,,-:-
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.e affirm that instructions have been given to C7£)R) � `
6------
ing 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
iciemairr )
is not responsible for the removal of personal items from the container or from the remains of the deceased. Personal items left In the
c • • with the remains will be destroyed by the cremation process and cannot be retrieved after cremation_
oIMte hereby authorize Pine View Crematory
pernidwymuns
to cremate the remains of the deceased.
FINAL DISPOSITION
The person authorized to receive the cremated remains of the deceased from the crematory is:
Name:My Staff from the Edward L Kelly Funeral Home
Address:1019 US Rt.9 PO Box 548,Schroon Lake,NY 12870 Phone:518-532 7177
The cremated remains of deceased will be disposed of as follows:
iT re fie— i-Qrgoy/ A/ J (S )
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
(cminablynismai
the remains to Edward L Kelly Funeral Home by delivery
(Funeral Home Name)
in person or by registered mail.
0r7 ip i I kt Maine(e tIo V Q-
DOS-1898-f(Rev.08/15) Page 2 of 3
r
Authorization for Cremation and Disposition
(1 'r�,"srst e lowing)
lIWe understand that if the remains are not claimed within 120 days of cremation,
Pi iew Crematory may dispose of the remains in
(Name of Crematory)
an irretrievable manner,such as by scattering.
CREMATION CONTAINERIURN
(Initial ONE of the following)
be used 'Tier for the remains has n purchased Edward L Kelly Funeral Home
and is dews foil
INVe understand that if the urn is too small to hold the entire cremated remains,an additional rigid container may be used for delivery.
-0R410
Ai An urn is not yet purchased. Me understand that if no urn is purchased or otherwise provided
P; �c wIr e.-K ! CV` will place the cremated remains in
(Name or
a rigid temporary container for delivery. //
This Authorization Form was provided by -el!7�1/V �F ! was executed at
y
Edward L Kelly Funeral Home
1019 US Rt 9,PO Box 548 Schroon Lake,NY 12870 Famed Home Name)
(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 islare 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 day of /)II�✓/gJ� .20 a--:
:y -
Name
y
Typed or Printed Name &Wore
Address
Typed arPrinted Nome *mem
Address
WITNESS:
(FuneralTyped orPreW Name) > Semite*
(RspOn NW �
11 9II) �- &ea Jo
ri-o s
!! Ai(Name ofDeaes-.O
DOS-1898-f(Rev.08115) Page 3 of 3