The URL can be used to link to this page

Blaney, Ruth Amoret Pine View Cemetery & Crematorium Quaker Road Queensbury, NY 12804 (518) 745-4477 or (518) 745-4476 FUNERAL HOME: 3 I j, / ' RETURN TIME: /1//H- DATE & TIME REMAINS ARRIVED AT CREMATORY: F` / Zz-.7 a NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS: Ph NAME: CASE # /D#7 TYPE OF CONTAINER: /Vic 4(1&i 5 (0 r tu��4 c+ � v-c 13erti PLACE OF DEATH: (//A); - i(S Ay( I( - /(X) PA/ ESTIMATED WEIGHT OF REMAINS & CONTAINER I s4 l b PLACED IN HOLD: 7d irr•, 12--;-7- ? PLACED IN REFRIGERATION: c-k1 DATE OF CREMATION: l-" '.9-e A) TIME STARTED: 2:?-y Aim TIME COMPLETED: rir3C,�'�,,, PLACED IN RETORT: 2'a4,1:-t /?-')-7-1-o MOVED: i",sy A1/vi, 9! JoArtp i RETORT# IN WHICH REMAINS WERE CREMATED: 5L4f_er per{ fI 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. 12/23/2022 FRI 10:59 FAX 21013/015 New York State Mose TY—NEW PORK Division of cE°�"°rtment� DM914N ot= lrf�es STA or One commerce Plefe - TY • ""°""'"'O . Cemeteries 99 Washington Avenue Albany,NY/MI-00m Telephone:(619)044226 • • www.der.ny.pev • Authorization for Cremation and Disposition This Aerie:eluton Form must be completed and signed priorte delivery of remains for cremation. bete; 12/23/2022 Number. /(.) ? Crematory Name:Pine View Crematorium nddrese:51 Quaker Road,Queensbury,NY 12804 Phone: (518)745-4477 CREMATION IS AN IfRREVItR1BLE 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 intones heat and flame. The heat and from will incinerate and consume everything except bone and metal, which era all that will be left after cremation. Following creMation,the crematory will fake reasonable effort*to remove al of the rumples and other materiel hem the cremation chamber,but zfome minimal dust and residue wink*be left behind. The crematory will separate Incidental and foreign material from the remains arid the Incidental and Foreign material will be disposed of es required by law. The cremated remains will be mechenIcefly pulverized idol small ploys and planed into a designated container or urn. Cremated remains generally are pulverized until no single fregrngnt le recognizable as skeletal tissue. OPENING OF TIKCONTAINER The• -. • in y only open the container holding the un-oremated human remains In limited circumstances,such as to oonamn the Identity of the deceased or to ensure that no material is enclosed which might injure employees or damage the crematory property_ If human remales ere deiyered in a container which Is not suitable for cremation such es ceremonial or rental casket.the cr+emetary require that the remain be moved Into a eulllabia container before It accepts the remains. The openlrrg 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 Q Name of Deceived: Ruth Amoret Blaney - Marital Status: Divorced Last wraum Address:1884 County Rt 43, Fort Edward, NY 12828 • Place of Death:Glens Falls Hospital, 100 Park Street, Glans Falls,NY 12801 Sex: O M I F Ape: 78 gm 10/23/1944 Data of Death: 12/15/2022 Estimated Weight 1 )) Desalpdon of iceek ti retainer in situate webs will bed d. LERSON 1N •• •LOP DISPOSA1 (Person(s)hi • hot of disposition,MI ONE of the following) I r m1We are the designated agent of the deceased designated In a will or written Instrument ezecutsd pursuant to Public - - Law Section 4201. ' -OR 1)D 5 14114e no knowledge that the deceased executed a written instrument pursuant to Public Health Low Section 4201 or a will containing • .-... . for the disposition of his or her remains and Uwe are the person(s)having priority under PuAAo Health Law Section 4201 - •• have the right to suthorlte cremation of the remains of the deceased. tuylOur midlonehlp to the deceased Is as Ruth Amoret Blaney D08.1898-f(Rev_04120) Page 1 of 3 12/23/2022 FRI 11:00 FAX a014/015 Authorization for Cremation and Disposition • (Insert from the Sat below) Number: 3 Description: Child 1. A person designated in writing pursuant to Public Hanlih Law Section 4201(4 2. The surviving spouse; 2s. The surviving domestic partner, 3. Any surviving child eighteen years of age or older, 4. A surviving parent; tf. A surviving sibling eighteen years of age or older; S. A lawfully appointed guardian; 7. Any pertson(s)eighteen years of age or older entitled to share In the estate and who is/are doeest in relationship to the deceased; a A duly appointed Ilduciary of the estate; ft. A dosei friend or relative who has executed a written statement pursuant to Public Health Law Section 4201(7); 10. A chief Oscar officer of a county or a public administrator appointted pursuant to the Surrogate's Court ProoedUre Act; My other person who is soling on behalf of the deceased and who has executed a written statement pursuant to Public Health Secylon 4201(7). (fria(ALL `1-EBof the followr7tg) hS IMie reby affirm that the body of the deceased does not oontaln a battery,battery pack,power cell,radlpwctive Implant • - .... +1. • - oe and that any such materials were removed prior to the execution of this Authorization Poem. Failure to remove these Items •i • to cremation may rasuk in harm to the oremabory and crematory personnel. X11 s —ii .affirm that Instructions have been given to W M. Buflch • 4• I! • removal of any personal property or other thing of value which any,person signing below or any family member of the deceased wlslies to preserve. _ _ Pine View Crematorium � reitsti + Ode for the removal of parsons]items from the container or Iran the remrdre of to deoessed. Personal items left In the / oonittlnar or h the manatee win be destroyed by the cremation process end cannot be retrieved after ereaation. .DtS i hereby authorize Pine View Crematorium true to cremate the remakes of the deceased. TM QP77ONAL) We hereby authorize the named funeral director to provide for delivery to and cremation by en abrade Crematory.if deemed neaeeay in the opinion of the funeral director,and to amend this form to provide the correct nano and seltheme of such alternate crentatory, FPIAL 0ISP08mop( The person mukhariaed to receive the cremated remains of the deceased from the crematory it: Name:Sin9l n Sullivan Potter Funeral Home,Wendy M. Bulich I. Address: 407 Bay Road, Queensbury, NY 12804 phone: . (518)793-4459 The cremated remain of deceased will be disposed of as follows: Burial—Glens Falls Cemetery If for any reason the person named above does not take possession of the cremated remains, Pine View Crematorium is authorized to give possession the rem to Singleton Sullivan Potter Funeral Homne by delivery t in person or by registered mat. Ruth Amoret Blaney (Nola or ostweasq DOB-1808d(lee.04/20) Pape 2 of 3 12/23/2022 FRI 11:00 FAX Qj015/015 Authorization for Cremation and Disposition earth ) • ilk I understand that if the remains ara not ciaimed within 120 drys of cremation, ` Pine View Crematorium _ may dispose of the remains in pm. creamy) an irretrievable manner,such as by scattering. SBE1�4N cONTAweRatat (mat ONE of the miming) An urn to be used as a container for the cremated remains has been purchased from end Is described as follows: 1IWe underatand that if the urn is too small to hold the entire cremated remains,an additional rigid container may be used for delivery. -OR um Is not yet purchased. IlWs understand that if no urn is purchased or otherMse provided Pine VView Crematorium _ will place the cremated remains In a rigid tempor4ry container for delivery. This Authortzalion Form wee provided by -- _Wendy M. Bulich was executed at Singleton Sullivan Potter Funeral Home _ 407 Road, ueinis e sbury, NY 12804 and is signed Lb(the funeral director es nitrites to its execution. UWs have rsc ilved a completed copy of this Authon6rstion Form. The personisil Identified below lefere the person(e)in control of disposition,who by signing this AuMofft elbn Form,attest(s) to the accuracy and cvmpl.bnsas of the information contained in this Authorization Form and a dirge)the folagobrg, signed this_23rd day of December 22 David Smith z irochr adednre:. P.O.Box 303,Caliente ,NV 89008- MMus i I�1 _ r ck,•. .ice'.• - . ;r- - Seder Awed Name 1 Q �rcr�� "`��A.}. �A�1Rx��-21 1%*-5.`.) WITNESS: ' \ Wendy M. Bulich \ �agalMeteor7yoeTdorw. sN�.s1 .n�n�►n rrrar.ole' (h m s►a•rw.l 10441 Ruth Amoret Blaney (NeatofDlem.rs Page 3 of 3 DOS-1898-f(Rev.04/20)