Bell. Margaret Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: 13P6A7._ RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: /01 201 7Z_ Z73°
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
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mum: nwtqlpo-- BEAL CASE # 13(1
T"PE OF CONTAINER: b4-41' Or` 11 6-1L0,44
PLACE OF DEATH: -f-JPA 1-1,031) P P3174 6:- fib Pt E.,
ESTIMATED WEIGHT OF REMAINS & CONTAINER itY At-
PLACED IN HOLD: _ _ _
PLACED IN REFRIGERATION: 2 ,Lio
DATE OF CREMATION: _ Zt n_
TIME STARTED: TIME COMPLETED: Z-
pp• )c,
PLACED IN RETORT: _ /(/'I MOVED: i/5-e)/1"-ei-•
RETORT # IN WHICH REMAINS WERE CREMATED: - (YU -rowfz.g- Ppie.
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
Department of State
rfiNEW YORK DIVISION OF CEMETERIES
STATE OF Division of
One Commerce Plaza
OPPORTUNITY,. 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.
10/20/22
Date: Number:
Crematory Name:
Pine View Crematory
Quaker Rd, Queensbury, NY 12804 518-745-4477
Address: 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 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
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.
IDENTIFICATION OF DECEASED
Margaret Bell Widow
Name of Deceased: Marital Status:
Fort Hudson Nursing Home, Broadway, Fort Edward, NY 12828
Last Known Address:
Fort Hudson Nursing Home, Broadway, Fort Edward, NY 12828
Place of Death:
Sex: O M E F Age:89 DOB: 2/6/1933 Date of Death: 10/19/22 Estimated Weight: 115
Description of casket/container in which remains will be delivered.
MacDonald Container; basic cardboard; no interior
PERSON IN CONTROL OF DISPOSITION
(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.
a
ar
I/We have no knowledge that the deceased executed a written instrument pursuant to Public Health Law Section 4201 or a
will o taining 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. My/Our relationship to the deceased is as
follows:
Margaret Bell
(Name of Deceased)
DOS-1898-f(Rev.04/20) Page 1 of 3
lI
Authorization for Cremation and Disposition
(Insert from the list below)
son
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 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 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 A THREE of the following)
I/We 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
thes- 'te•• •rior to cremation may result in harm to the crematory and crematory personnel.
Patricia Miller
1're I/We affirm that instructions have been given to
(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
Pine View Crematory
deceased wishes to preserve.
(Crematory Name)
is not responsible for the removal of personal items from the container or from the remains of the deceased. Personal items left in the
coAA- iner or with the remains will be destroyed by the cremation process and cannot be retrieved after cremation.
.r I/We hereby authorize Pine View Crematory
(Crematory Name)
to cremate the remains of the deceased.
(Initial OPTIONAL)
llwe 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:
Brewer Funeral Home, Inc.
Name:
24 Church St., Lake Luzerne, NY 12846 518-696-2744
Address: Phone:
The cremated remains of deceased will be disposed of as follows:
returned to family
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 Brewer Funeral Home, Inc. by delivery
(Funeral Home Name)
Margaret Bell
in person or by registered mail.
(Name of Deceased)
DOS-1898-f(Rev. 04/20) Page 2 of 3
ilk.
Authorization for Cremation and Disposition
)ti a following)
I/We understand that if the remains are not claimed within 120 days of cremation,
iew Crematory
may dispose of the remains in
(Name of Crematory)
an irretrievable manner, such as by scattering.
CREMATION CONTAINER/URN
(Initial 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: .
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.
Z-O
An urn is not yet purchased. I/We understand that if no urn is purchased or otherwise provided
View Crematory
will place the cremated remains in
(Name of Crematory)
a rigid temporary container for delivery.
Patricia Miller
This Authorization Form was provided by was executed at
(Funeral Director Name)
Brewer Funeral Home, Inc.
(Funeral Home Name)
24 Church St., Lake Luzerne, NY 12846
(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 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 authorize(s)the foregoing.
20 October 22
Signed this day of , 20 - 3
/�TypMichael Bell c..
ed or Printed Name
J�gnature jv
2924 North Shore Rd., Hadley, NY 12835
Address
Typed or Printed Name Signature
Address
Typed or Printed Name Signature
Address
WITNESS: J/
Patricia Miller t� N Wl A it �f All 1
(Funeral Director Typed or Printed Name) (Funeral Director Signature)
12465
(Registration Number)
Margaret Bell
(Name of Deceased)
DOS-1898-f(Rev.04/20) Page 3 of 3