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Hallowell, Douglas Pine View Cemetery & Crematorium Quaker Road Queensbury, NY 12804 (518) 745-4477 or (518) 745-4476 FUNERAL HOME: __ JZ Q S RETURN TIME: DATE & TIME REMAINS ARRIVED AT CREMATORY: ICU (x)(111 NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS: NAME: U.6-1 Pt 5 1-161. �'la ((, CASE # !i I TyPE OF CONTAINER: -__- rnt i 4 1 FIL-r. ve PI.ACE OF DEATH: . Oks_ _ Cti Ill lus i f i..i ESTIMATED WEIGHT OF REMAINS & CONTAINER PLACED IN HOLD: 11'10 PLACED IN REFRIGERATION: DATE OF CREMATION: ,,,, .._.°_.-.._.3.. Z-1 TIME STARTED: 2`�Q/��//��"yyl -_ TIME COMPLETED: I' ©krfr'► PLACED IN RETORT: .074/0/ri MOVED: /0 3-_.5- RETORT # IN WHICH REMAINS WERE CREMATED: St'fLIL _ WAR- 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. gI� 3 Nee VorY Vete NEW YORK Division of Orporonern Siam STATOf DmaiON CEMETERIES °"`"T°""y Cemeteries One 99 . Avenue A tang NY/22N 0001 Trre�tms(518)446/26 en.dosoy9w Authorization for Cremation and Disposition This Authorization Form must be completed and signed prior to delivery of remains for cremation. Dale 10/07/2022 Crematory Name Pino View Crematorium _ Address SI Quaker Road_Queensbury,NY 12804 ___� hone (518)745-4477 CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS. Cremation te Carried out by placing the remains of the deceased and the ontamer holding the remains into a cremation chamber where they aro eubjecred to Intense heat and Yams.The heat and flame will Incinerate and consume everything*scope bone and metal, which are all that will be left after cremation. Following cremation,the crematory wit take reasonable effort to remove all of the remains and other material from Ili crer aeon chamber,but some minima dust and residue will likely be left behind.The crematory will samosa incidental and foreign materiel from the remains and the incidental end foreign material wed be disposed of as required by law.The crenated 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 le recognizable as akeMat tissue. OPENell OF THE CONTAIIER The crematory mey only open the container holding the un-Cremated human remains n Walled araaneancas,such as to confirm the identity of the deceased or to ensure that no material Is enclosed which might injure employees or damage the aenatory property.I human remains are delivered In a Container which is not suitable for cremation such as ceremonial or rental casket,the crematory wed require that the tamable be moved Into a suitable container before It accepts the marine The opening of container or the transfer or removal of remains will be conducted before a witness and will be done in privacy,with direly and retpsa. JQ€JTWICATION OF DECEASED Name of Deceased Douglas A.Hallowell Nadel Status Divorced test known Addfess:17 Back Searsport Rd.Belfast,ME Place W Death:Glens Falls Hospital,100 Park Street,Glens Falls,NY 12801 sex_®M 0 F Ages 58 DOB- 10/12/1965 Date of Deathc 10/04/2022 EstimMed Weight ip Description of casket/container in which remains wet be delivered. Fibberboard/alternathro container,Matthews Company perms OF Dt=rimanium / /�H CONTROL I atnMe are the designated agent of Ste deceased designated in a wB or written insiunent elsatedpursue>t to edit Health Law Section 4201. ,V" 11 We have no knowledge that the deceased exewted a wnitam instrument pursuant to NM HesAh Lee Section 420i a a veil containing directions for the disposition of his or her remains and I/we are the person(s)having OWN hew 10 1 Pubic Hes tin nNosas.d is setaw Sed w ion 4201 and have the rig of to authorize cremation the remains of She deceased.UytOur tltYBattahb followre: 1 ra Douglas A.Hallowell pees ro.ww.A Page t of 3 DOS-1898-f(Rev.04/20) jai I Authorization for Cremation and Disposition (Insert hwn the kb below) Number—#3 DosrnPeon Surviving chit 1. A person dessanaled in swamp 2. T 9 Pursuant to Pubslc Health The surviving spouse, Lew Sedron 4261(Ji 2a. The Wrvenng domestic partner 3. My sutvmng ched e 4. A su ghaen years d age a rider 6 su . A mg Parent. S. A rvng sibling eighteen years Cl age or older, 7. iastu9Y*Pointed guardian, My Person(s)eighteen years of age or older entitled to share in the estate and who is/are closest in reiatbnsh,p to the deceased N appointed fiduciary of the estata: 9. A dose friend or relative who has executed a onion statement pursuant to Pubbc Health Law Sect,on 4201(71. 10. A chief fecal officer of a county or a pubsc administrator appdnled pursuant to the Surrogate',Court Procedure Act, 10a. Any other person who a gang on hehetl d the deceased and who has executed a written statement pursuant to Pubic Health .any, other p rson4201(7) wl—�tne kW/owing, IbVe hereby affirm that the body of the deceased does not cattam a battery,battery pack or radtoacrive device and that anysuch power core radioactive instant matenals were removed poor to the eaacutnn of this Authorimbon Form Failwe to remove these items prior to cremation my mutt M lens to the crematory and crematory personnel. 1t1N°iffrtrn that instructions have been gwen to Sarah A.Phib regarding the removal of an _-- -'-y pe soda property or doer thing ofvalue which any person wooing babes or artym faJy memberof the deceased wishes to preserve Pine View Crematorium e not responside In,the removal of personal items horn the container or from the ro• items mans of the deceaseded Persons; heft in the container or with the remains will be destroyed by the cremation process and cannot be retrieved after cremation MN*hereby authorize Pine View Crematorium oar e.v (/ref oPnwvAL) Ia cnmea Sr.remains of the deceased. a hereby uthodta the al d to provWe end c address alternate ry in the of the fume .and a arrant ea pr an correct name FMIAL DISPOSITION The person authorized to receive the aemated remains of the deceased horn the crematory is Name.Regan Denny Stafford Funeral Home,Sarah A.Philo Address 53 Quaker Road,Queensbury,NY 12804 phoro:_ (518)792-1114 The cremated remains of deceased we be disposed at es fotlovrs. Cremated remains(ashes)to be mailed to daughter Ashley If for any reason the person named above does not take possession of the cremated remains. Pine View Crematorium num..",wee rs authorizedtogive possessed c1 the remans fo Regan Denny Stafford Funeral Home In Parson or 0 r tn..,o o Pow* ___by defrvery y eg stereo mail Douglas A.Hallowell vowwwq Page 2 of 3 DOS-18981 fRev 04/20) lei Authorization for Cremation and Disposition 0.+2 ga,the 10NOun^9) INye underhand that 4 the remans are not eta aihhed within 120 days o1 cremator Pine View Crematorium an metnevabie manner,such as by Scatteringmay Qsppse of the.emans,n C NATION CONTAINER,URN (In r t,ONE W the tdbwnagl _An An urn to be used as a container for the cremated remains has been purrnasr.d frmo Regan Denny Stafford FllnPra, and a described as karats thee understand that the on a too small to hold the entire cremated remains an addlronai nob container may be used for delivery -OR- Air um a not yet purchased INve understand that if no urn is purchased or otherwise provided Pine View Crematorium v al place the Cremated remains in a ngo temporary container for del,very Tans Authorization Forth was provided by Sarah A Philo rr„o,,,a,�.�, was executed at ---------_.._ Regan Denny Stafford Funeral Home 53 Quaker Road,Queensbury,NY 12804 and is signed by the funeral director as witness to its execution. _. tithe have received a completed copy of this Authorization Form. tThe p rson(s)We/UMW Wow Went the p csellis)In cormol of disposition,who by signing this Authorization Form.atlesas) curacy and completeness of the brfom»non contained in this Autl odzedo r Form and euthodzets)the foregoing. signed this 7th ay of October 20 22 Ashley Ashby 712 Blake Rd,Limestone,ME 04750- AIM b $-tabS Moran Stab y Punic Maine my.Commission Lon., -S; r V r� of neizt.,u_ y�T.�oz3 Siiurnp!Seek!? of (\lot Douglas A.Hallowell Ire..ala.e.r.q DOS-1898-1(Rev 04l20) Page 3 o13 `a