Fellows, Paul Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: Kzet 11,*-42_ RETURN TIME: _
DATE & TIME REMAINS ARRIVED AT CREMATORY: / 3064-1
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
Kmbif. LIKEz
NAME: ut e,_tcov 6- CASE # L
T'"PE OF CONTAINER: Port NA (5104 /O. 'Re 76'41604
PLACE OF DEATH: Li Z
(don c-y-t OvoAsWri1
ESTIMATED WEIGHT OF REMAINS & CONTAINER / l_5.0 /56— 5c41c9/
s4C
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION: /OM 71..
TIME STARTED: /./01 TIME COMPLETED:
PLACED IN RETORT: __ MOVED: 2 1001 2, soft,
RETORT # IN WHICH REMAINS WERE CREMATED: P fA V
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
Deportment of sm.
NEM/YiORK Division of DIVISION OF '�
STATE OF One Commerce Plaza
° �'"'T' Cemeteries 99 Washington Avenue
Albany,NY 12231-0001
Telephone:(51a)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;Jan.30,2022 '1 q I
Number:
Crematory Name.Pine View Crematory
.Quaker Road,Queensbury,NY 12804 518-745-4477
Address
Pitons:
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
and
Cremation is carried out by placing the remains of the deceased the container holding the remains into a cremation chamber where
they are subjected to intense heat and flame. The heat and flame will inclnente 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 cremationn
chamber,but some minimal dust and residue will likely be left Yehind. The crematory will separeee 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. N
human remains are delivered Ina container which is not suitable for cremation such as ceremonial or rental casket.tie
crematory will require that the remains be moved Into a suitable container before it accsets tie 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 Paul Fellows Marital Status:tMdowed
:80 Alen Road,Argyle,NY 12909
Address
.s' 42 Gurney Lana.QrMsnbury,NY 12804
y �� : F llimC
89 DOE:01/02/1933 Date of Death.10 022 Estimatedwieighc 150
eeprl) pnxtfruyal(etleortbinar hwhich remains will be delivered.
Casket-Florence Casket Co. Pine/Cardboard
r
�aq rp/ddtapoaltfa>4 (DAIStithedl oie*ig)
"'4' , . . .; in a will or written instrument executed pursuant to Public
" a1M the dsslpntled agent ttf the deceased dselprte�ed
Ir 4201.
s ` ,xf
-' i L • have rtp blowledpe thet the deceased a aMc iaa a wfkn insure pe a pursuant>b Public Health Law Section 4201 or a
41�v r� sa +iprt Iklai n of his or her r main s WMM it"
aisle peraon(s)having priority under Public Health Law
, "" ° , y , hays#fie ru t to m ortoa aanaicn ci piths mmihi tithe d.o.as . My/Our relatIontshlp to the
deceased teas
� Owed dossrad)
�� ' y Paul lows
Page 1 of 3
,..,,, w ; . .w' 0I120)
a'„ rr°�' ,4"t as
Authorization for Cremation and Disposition
(Insert from the list below)
Number 3 pescnption• Any surviving child 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. 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. 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 Mend 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 Ad;
10a. My 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).
(►n'. THREE of the following)
i 61.
`�= Ile*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.
`�J"I►4Vs affirm that instructions have been given to Katie Morehouse (Funs'a.aa Moe)
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
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.
/==I I/W,hereby authorize Pine View Crematory rr..moby>+.
to cremate the remains of the deceased.
(Initial OPTIONAL)
Uwe 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 DISPO5f1'tOP(
The person authorized to receive the cremated remains of the deceased from the crematory is:
Name:M.B.Kilmer Funeral Home
Address: 123 Main Street Argyle.NY 12809 Phone: 518-638-8216
The cremated remains of deceased will be disposed of as follows:
pleas r'i&fa cor-ni--Iwv wig in far-filge4r'61""''1''ahr"y.
if for any reason the person named above doss not tale possession d the cremated remains.
Pins View Crematory is authorized to give possession of
Kweemyrisee
ha rMnaUhs to M.B.IQmar Funny Harm by delivery
r+eriwicarrrrw
_.,In person or by registered map. Paul Fellows
rrim.d Ororoel
;DOS-18N4(tisv 04120) Page 2 of 3
Authorization for Cremation and Disposition
(Initial th owing)
understand that if the remains are not claimed within 120 days of cremation,
Pine View Crematory may dispose of the remains in
rwwv or Crematory)
an irretrievable manner,such as by scattering
CREMATION CONTAINERIURPj
(Lail I ONE of the following)
An urn to be used as a container for the cremated remains has been purchased from
and is described as follows: •
INVe understand that if the urn is too small to hold the entire cremated remains,an additional rigid container may be used for delivery.
ei:i?...
.n um is not yet purchased. INVe understand that if no urn is purchased or otherwise provided
Pine View Crematory will place the cremated remains in
tww.of CieilotoM
a rigid temporary container for delivery.
Katie Morehouse was executed at This Authorization Form was provided by
(Arnow O roceor a ror
M B Kilmer Funeral Home
(FWwu Mow.maw
123 Main Street,Argyle,NY 12809
"F,.*W Mcrae Admen)
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[stare the person(s)in control of disposition,who by signing this Author/zatlon Form,ataest(s)
to the accuracy and completeness of the information contained In this Autho •• .• • d arutirorb»(s)fie forpoing.
Signed this 3rd day of October ,20 22
Villein Fellow /__ O.
Awes
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