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Dubrule, Gregory S. { y Pine View Cemetery & Crematorium Quaker Road Queensbury, NY 12804 (518) 745-4477 or (518) 745-4476 FUNERAL HOME: Kf,1,01 RETURN TIME: TIC si919 y DATE & TIME REMAINS ARRIVED AT CREMATORY: /I/0 1Z 2:41 NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS: aogo ecC'f NAME: F F 0►Qki .Pu p e ti CASE # Z TYPE OF CONTAINER: 1b4 2/ (e.1-io f , -e /i 1 dl PLACE OF DEATH: IN i fIl ly %h1'1'" (purr sC 4,,.o I hvi6 Mi. l7 lv ESTIMATED WEIGHT OF REMAINS & CONTAINER (IV IL- 5'1-cif PLACED IN HOLD: PLACED IN REFRIGERATION: DATE OF CREMATION: Il I H/ZZ TIME STARTED: TIME COMPLETED: ,pit--, i 7 )�� PLACED IN RETORT: I d `/D is MOVED: J G:�cA` / /I ' 1 d°1' ' [kV D RETORT# IN WHICH REMAINS WERE CREMATED: 50196 X f90w4 PA(( 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 TXNEW YORK Division of SON O oET State STATE OF One Commerce Plaza L j _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. Date: II I gI 1 L Number: �7 Crematory Name:Pine View Crematory t� vt Address: i; Q v rk ll r L (Uf,,E0458 /' i7 U.j Phone: C1 ))C11` !4M 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 ail that will be left after cremation. Following cremation,the crematory win take reasonable efforts to remove all of the remains and other material from the cremation chamber,but some minimal dust and residue sell 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 Name of Deceased: 61-Q,FB r tor - `.9•J )i-v I e_ Marital Status: /�A NI Last Known Address: /r� IJII `7 P.8 to AT-J VI%G- f �" a/5Y (y I .. C Place of Death: /1j . AAyj i,. IA C w r T" S�j r�C7/L� t- J d�4 —16 Sex: t�-M ❑F Age: (O — DOB: ©a / J 9Ga Date of Death: //Adap 7,9001v... Estimated Weight:/ft' Description of casket/container in which remains will be delivered. /a re-J C.4_ 62 f4/n7 jai 1J (2a irri j l.J Q I• PERSON IN CONTROL OF DISPOSITION (Person(s)in control of disposition,initial ONE of the following) the designs gent of the deceased designated in a will or a n£to Public He Law Section 4201. -OR- 1 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 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 relationshipn to the deceased is as follows: Y✓(� 13, J 1'� mete of Deceased) DOS-1898-f(Rev.08/15) Page 1 of 3 Authorization for Cremation and Disposition (Insert from the list below) Number: Description: --31)61 Q------ 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 dosest in relationship to the deceased; 8. A duly appointed fiduciary of the estate; 9. A dose 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). (J ALL THREE of the following) 1/We hereby affirm that the body of the deceased does not con= batterx-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. pld3 llWe affirm that instructions have been given to (Funera)OFmCNaName) (\/ 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 (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 container or with the remains will be destroyed by the cremation process and cannot be retrieved after cremation. cyV/3 uwe hereby authorize Pine View Crematory (CnenatayName) to cremate the remains of the deceased. FINAL DISPOSITION The person authorized to receive the cremated remains of the deceased from the crematory is: Name:Any Staff from the Edward L Kelly Funeral Home Address: 1019 US Rt.9 PO Box 548,Schroon Lake, NY 12870 Phone:518-532 7177 The cremated remains of deceased will be disposed of as follows: e1we- 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 Edward L Kelly Funeral Home by delivery (Funeral Home Name) in person or by registered mail. � 00,6e- I4- cNama�o DOS-1898-f(Rev.08/15) Page 2 of 3 Authorization for Cremation and Disposition (Initial the following) I/We understand that if the remains are not claimed within 120 days of cremation, Pine View Crematory may dispose of the remains in (Name or Crematory) an irretrievable manner,such as by scattering. CREMATION CONTAINER/URN (Initial ONE of the um to be use containe r the ore d remaf s h een purchased and L y ral Ho e and is d scribed as follows' UWe untiefstand 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 is not et purchased. I/We understand that if no urn is purchased or otherwise provided !N u e- ()(gGJ ei,e44/F1 !�' 1'/ will place the cremated remains in (Name of Crematory) f a rigid temporary container for delivery. � J This Authorization Form was provided by " � ( ('V k /1,ç / was executed at (FuneralDirectorName) Edward L Kelly Funeral Home (Funeral Home Name) 1019 US Rt 9, PO Box 548 Schroon Lake,NY 12870 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 islare the person(s)in control of disposition,who . i�nin� Authorization Form,attest(s) to the accuracy and completeness of the information contained in this A nzation Form and a ' s foregoing. Signed this 5711i day of 1t5 C U Q')1 A"— ,20 g---. a"at. 15 /,d__a , /j/blvt. - Typed orPdnfed Name Address JAZ /70 AlL /ed T cr nfed re j F-,, /i// 4 / 6,5 are /[ � Typed or Printed Name Signature Address WITNESS: oi� j' �-/ (Forrest Director Typed Prtnfed Name) (Funeral ) 11 &s"7 (Registration Number) he-yeI ' flit ry /42-- (Name of Deceased) DOS-1898-f(Rev.08/15) Page 3 of 3