Scott, James E LF)
Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: 6k%CIt( f th.irjeAL MAL RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: 11 IIki ill 2.0011
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
Kue6.
NAME: 7A 14ES E , 5/Drr CASE # /31
TYPE OF CONTAINER: CCICOld TScv zo = Q ( /i5j CN&CAi
PLACE OF DEATH: 5111 -t•N+JSEu h (Z0ko, roc EPOa�0.1D J4 1751g
ESTIMATED WEIGHT OF REMAINS & CONTAINER /7��5 44.L� 270 Ur-
PLACED IN HOLD: ?;z Ph
PLACED IN REFRIGERATION:
DATE OF CREMATION: /Z-/6-Zr'z
TIME STARTED: %0 TIME COMPLETED: /Z
PLACED IN RETORT: D MOVED: //
RETORT# IN WHICH REMAINS WERE CREMATED: ,D voCat,--
ciJK-
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 F THE CREMATORY.
69/11/2017 00: 49 13153532;89 PAGE 02,104
New"ark State
Department of State
rdrNEW YORK 1 Division of DIVISION OF CEMETERIES
STATE OF One Commerce Plaza
OPPORTLINiTY 99 Washington Avenue
Cemeteries Albany,NY 1231-0001
Telephone:(518)4746226
;rhvw.dos.ry.gov
Authorization for Cremation and Disposition
This Authorization Form must be completed and signed prior to delivery of remains for cremation.
Date: 1V11-0 Z�. — Number, ci��
Crematory Name: `T tal-A --Si,►, `4 AP — --
Address: 4 j Cr % . V 45V+y,1" - Phoneme
i CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation e 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 aU that will be left after cremation.
Following creration,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 cran1atory will separate incidental and foreign material from
III,the remains and the incidental and foreign material wil be disposed of es required by law. The cremated remains will be mechanically
pulverized into srnai'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 cr removal of remains will be conducted before a witness and will be done in privacy;with dignity and respect.
IDENTIFICATION OF DWEASED
Name of Deceased; Q.Y e.S C Marital Status:_, L)
Last Known Address:. :1"t°1. �ri .xao 'a=' VOA + IN-TA .(t,Z%
Place of Death: Coo v1,e` a..5 `�'1 - "-
Sex: riztA ri F Age:J ► DOB: Ck--aS . ,IR toy Date of Death:V 2- '-. lO2. Estimated Weight: Z ZO
Description of casketicontairter in which remains will be delivered. 0
PERSON IN CONTROL OF DISPOSITION
Person(s)in control of disposition,. initial ONE of the following)
a iANe are the designated agent of the deceased designated in a will or written instrument executed pursuant to Pubic
Health Law Se on 4201,
-OR-
- e have no knowledge that the deceased executed a written instrument pursuant to Public Health Law Section 4201 or a
will 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. MylOur relationship to the deceased Is as
follows:
(Name no )
DOS-189S4(Rev. 04/20) Page 1 of 3
. OS/11;2017 00: 4ci 1 315353'. �i-- PAGE 03/04
Authorization for Cremation and Disposition
(Insert from the list below)
Number: Description:
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 order;
4. A surviving parent;
6. A surviving sibling eighteen years of age or 3Ider;
S. 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;
8. A close friend or relative who has executed a written statement pursuant to Public Health Law Section 4201(7);
10. A chits,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).
( lief ALL THREE of the following)
INVe 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 cremate personnel.
IfWe affirm that instructions have been given to ,A. \C)
rump'Director Noma)
regarding the removal of any personal property er thing of value which any person signing below or any family member of the
deceased wishes to preserve. „_., - tt`'3Q V �'w &'Y
'' 1d Xy 1
(cramarory Ns,*
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/We hereby authorize ir..B:V-.. ` -- "'e'an51A°'f
(rr9maray valo
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 DISPOSITION
The person authorized to receive the cremated remains of the deceased from the crematory is:
Name. .` O U c + V 2..1 4 r). -\1�)1''...-; r ` , _ --
Address.. (;itit .-1:._ 1)0's IC1.a. NCN 1, Phone. . -353--'2t1Z
The cremated remains of deceased will be disposed or as follows.
Vv., o — --- _ --
If for any reason the person named above does not take possession of the cremated remains,
is authorized to give possession of
- (Crem®roryNerai)
r
_ .)c\`. Vv�,ra,...51 ..�‘�.. ". �,c' by delivery
the remains to_ /rues kome Nam -�1
in person or by registered mail. QY"•.e� r�- c.TC 5C
.'Name of Ceceasa+d)
DOS-1898-f(Rev.04/20) Page 2 of 3
t9/11/2017 00: 49 13153532_'39 PAGE e.d/Ft4
Authorization for Cremation and Disposition rrow.
(Iniria(the following)
_ .INVe understand that if the remains are not clamed within 120 days of cremation,
' may dispose of the remains in
Name or t?rsn+eray
an irretrievable manner, such as by seafaring.
CREMATION NTA ERtURN
(Initial ONE of the following)
_An urn to be used as a container for the cremated remains has been purchased troll -
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" not yet purchased. INVe understand that if no urn is purchased or otherwise provided
lc)
w1.r9.2v Q.w G(Q,\r„ti4:. � _ will place the cremated remains in
— (Nam aCremetivy
a rigid temporary container for delivery. ,--- ,---
�, �11w �_—.-__,.wrvas executed et
This AuthoriZ Form was provided by- (Funerw Cireciorrvatr )
Ti72.)\,)
r- (Fur +Home,vaMe) w �, 0 _. _
!F.w�at+rron,a Address,
and is signed oy the f tnerai director as witness to its execution,
liWe have received a completed copy of this Authon'aelonl Form. _.._. _- `\�,.,.
The person(s)identified below ialere the person(s) f
In control fposition,who ty signing this o don Form,attest(s)
to the accuracy and completeness of the information con led In this Authorization Form and authn =e(. the foregoing.
1 raly � ,20 Z2� '
led this _ f�- „day of___ - �-Y
Tveeorpdnted NJyy� ''` `' na a'
nrmrees �'—'�"
Typed or Palled Neme &velum r __..„--
Adynws
7ypc�iorPinleCName ---- SfQreWre -.—
adweaa --_ — — —
WITNESS: ,- \ L� �y "- `�
-_�r>�.a �� '�Lsz- ,�,drnnd�is her,,-)
{cures,Director TYPaa nr Pndterl Neme) -
arJrrrrration .u.mber)
(Name or Deceased)
DOS-1898-f(Rev.04/20) Page 3 of 3