Como, Alan [cf.)
Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: h,} ru.k 'a RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: 17112.2 2-
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
- - _ hDRe kd-(
NAME: _ JUA IJ (Wa CASE # 1--)Z
TYPE OF CONTAINER:
PLACE OF DEATH: (D .-..__1-14„ 70" +. IT) Sov}. ���� t-41 (7(603
ESTIMATED WEIGHT OF REMAINS & CONTAINER 2Ts IL- /314 j1,5-s '
PLACED IN HOLD:
PLACED IN REFRIGERATION: 3'con
DATE OF CREMATION: yIZ�I1Z -
TIME STARTED: �' ZO TIME COMPLETED: D'11_611/
PLACED IN RETORT: -71L1141 MOVED: 9 3'_ 71 I oml
RETORT # IN WHICH REMAINS WERE CREMATED: w1E$_ '
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
NerrIEW YORK Division of Department CEM of
T s
DNISI STATE OF ON OFFCF.METt?RtES
OPPORTUNITY..
Cemeteries One Commerce Plaza
99 Washington Avenue
Albany,NY 12231-0001
Telephone:(518)4746226
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:September 23,2022
Number.
Crematory Name:Pine View Crematory
Address:21 Quaker Road, Queensbury,NY 12804 518-745-4477
Phone:
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 hest and flame wSl 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
JDENTIFICATION OF DECEASED
Name of Deceased:Alan Como Never Married
Marital status:
Last Known Address: 102 Hudson St.Apt. 1 B South Glens Falls,NY 12803
Place of Death: 102 Hudson St,Apt. 1B South Glens Falls,NY 12803
Sex: El M 0 F Age:71 DOB: 10/18/1950 Date of Death:09/14/2022 Estimated Weight 225
Description of c asket/contalner in which remains will be delivered.
Minimum Cremation Casket, Florence Casket Co. Cardboard/Pine
PERSON IN CONTROL OF DISPQSITIOH
(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-
Av.!d 4 i l/We have no knowledge that the deceased executed a written instrument pursuant to Public Health Law Section 4201 or a
will .•n =ining directions for the disposition of his or her remains and I/we 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. MylOur relationship to the deceased is as
follows:
Alan Como
(Named Deceased)
DOS-1898-f(Rev.04/20) Page 1 of 3
Humornzation for Cremation and Disposition
(Insert from the list below)
Number. 5 Description: A surviving sibling eighteen years of age or older
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 duty 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 THREE of the following)
IIWe 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 Morgan Wicks
(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
((leneloryNeme)
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.
1/We hereby authorize Pine View Crematory
lasmmayNs.ui
to cremate the remains of the deceased.
(Initial OPTIONAL)
Ilwe 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: M.B. Kilmer Funeral Home
Address: 136 Main St South Glens Falls,New York 518-745-8118
Phone:
The cremated remains of deceased will be disposed of as follows:
Mailing ashes
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 M.B. Kilmer Funeral Home by delivery
neral Home
in person or by registered mail. (Fu )
Alan Como
(Name of Deceased)
DOS-1898-f(Rev.04/20) Page 2 of 3
Authorization for Cremation and Disposition
(dd&the following)
I/We understand that if the remains are not claimed within 120 de..s of cremation,
Pine View Crematory
� ,) may dispose of the remains in
an irretrievable manner,such as by scattering.
CREMATION CONTAINER/URN
(1jJ ONE of the following)
An urn to be used as a container for the cremated remains has been purchased from M B Kilmer Funeral Home
—,
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-
��� An urn is not yet purchased. I/We understand that if no urn is purchased or otherwise provi
ded
ed
Pine View Crematory
Name orc,emarory) will place the cremated remains in
a rigid temporary container for delivery.
This Authorization Form was provided by Morgan Wicks
(FneralDNsctorNone)
was executed at
M.B. Kilmer Funeral Home
136 Man St.South Glens Falls New York (F Name)
(Funeral Horne 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 persons)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 authorizes)the foregoing.
Signed this 23 day of September 2022
' ,
Mary Ann Presutti
Typed or Pentad Name
2294 Leanne Swamp Road,Murfreesboro,TN 37129
Address
Typed or Printed Name
Signature
Address
typed or Printed Name
Address
WITNESS:
Morgan Wicks
(Funeral Director Typed or Printed Name) (Frrn+ra saor Signature)
14694
(Aepababon Number)
Alan Como
(Neme of Deceased)
DOS-18984(Rev.04/20) Page 3 of 3