Randolph, Clarence L {' S
Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: S S p RETURN TIME: MOPE-
DATE & TIME REMAINS ARRIVED AT CREMATORY: I I ' A I ZZ /J - 3O 1 ' 1
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
NAME: QltWegE PrnlDOL P -4 CASE #
TYPE OF CONTAINER: I3u{4tlo ( Icti- Allopt+11 i -17,k
•
PLACE OF DEATH: Z'I (Ls4-0 gtcist Rid 1 4 wt^S ' f IT Uj
ESTIMATED WEIGHT OF REMAINS & CONTAINER 2?'S it, .5,-14
PLACED IN HOLD:
PLACED IN REFRIGERATION: Ij Sys P1/
DATE OF CREMATION: !1 19 /7Z
TIME STARTED: TIME COMPLETED: q 11 oS
PLACED IN RETORT: it MOVED: I S 10 IO 4 r
RETORT# IN WHICH REMAINS WERE CREMATED: iNEE. f AIC T /D'yo0:
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
Depament of State
,,,r7NEW YORKDIVISION OF CEMETERIES
STATE OF Division of
One Commerce Plaza
OPPORTUNITY.
Cemeteries 99 Washington Avenue
Albany,NY 12 2 31-00 01
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: 11/07/2022 Number: Q)k
Crematory Name:Pine View Crematorium
Address:51 Quaker Road, Queensbury, NY 12804 Phone: (518) 745-4477
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
Name of Deceased: Clarence L. Randolph Marital Status: Married
Last Known Address:251 Chestnut Ridge Rd., Queensbury, NY 12804
Place of Death:' 251 Chestnut Ridge Rd., Queensbury, NY 12804
Sex: ®M CI F Age: 88 DOB: 06/23/1934 Date of Death: 11/06/2022 Estimated Weight:
Description of casket/container in which remains will be delivered.
B040 �7si (,i l0,,I l j?..
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
H= aw Se.ion 4201.
-OR-
e have no knowledge that the deceased executed a written instrument pursuant to Public Health Law Section 4201 or a
will contai ' g directions for the disposition of his or her remains and I/we are the person(s)having priority under Public Health Law
Section 01 and have the right to authorize cremation of the remains of the deceased. MylOur relationship to the deceased is as
.1Io -:
Clarence L. Randolph
(Name of Deceased)
DOS-1898-f(Rev.04/20) Page 1 of 3
Authorization for Cremation and Disposition
(Insert from the list below)
Number: 2 Description:Spouse
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
-w -, 'on 4201(7).
(Initial ALL THRE- of the following)
!lf" I/We •ereby affirm that the body of the deceased does not contain a battery, battery pack, power cell, radioactive implant,
.r„;;• «' - device and that any such materials were removed prior to the execution of this Authorization Form. Failure to remove
these items p 'or to cremation may result in harm to the crematory and crematory personnel.
e', 11W affirm that instructions have been given to Robert Barbieri
(Funeral Director Name)
ar•••- e 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 Crematorium
(Crematory Name)
is es ible for the removal of personal items from the container or from the remains of the deceased. Personal items left in the
container or w h the remains will be destroyed by the cremation process and cannot be retrieved after cremation.
\-4fet I e hereby authorize Pine View Crematorium
(Crematory Name)
to cremate the remains of the deceased.
(Initial OPTIONAL)
Ilwe 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:Singleton Sullivan Potter Funeral Home, Robert Barbieri
Address: 407 Bay Road, Queensbury, NY 12804 Phone: (518) 793-4459
The cremated remains of deceased will be disposed of as follows:
Return to family
If for any reason the person named above does not take possession of the cremated remains,
Pine View Crematorium is authorized to give possession of
(Crematory Name)
the remains to Singleton Sullivan Potter Funeral Home by delivery
(Funeral Home Name)
in person or by registered mail. Clarence L. Randolph
(Name of Deceased)
DOS-1898-f(Rev.04/20) Page 2 of 3
Authorization for Cremation and Disposition
�n1 ra ollowing)
°f C� I e understand that if the remains are not claimed within 120 days of cremation,
Pine View Crematorium may dispose of the remains in
(Name of Crematory)
an irretrievable manner,such as by scattering.
CREMATION CONTAINER/URN
(Initial ONE of the following)
Singleton Sullivan Potter
An urn to be used as a container for the cremated remains has been purchased from p,in r•ni i. r mo
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-
�it- An im is not yet purchased. I/We understand that if no urn is purchased or otherwise provided
Pine View Crematorium will place the cremated remains in
(Name of Crematory)
a rigid temporary container for delivery.
This Authorization Form was provided by Robert Barbieri was executed at
(Funeral Director Name)
Singleton Sullivan Potter Funeral Home
(Funeral Home Name)
407 Bay Road, Queensbury, NY 12804
(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 t Authorization Form,attest(s)
to the accuracy and completeness of the information contained in this Authorization Form and autho ' s)the foregoing.
Signed this 7th day of November ,20 221
Helen Randolph .,( � RAS
Typed or Printed Name to
251 Chestnut Ridge Rd., Queensbury, NY 12804-
Address
Typed or Printed Name Signature
Address
Typed or Printed Name Signature
Address 6
WITNESS: —
Robert Barbieri ���. (,L..
(Funeral Director Typed or Printed Name) (Funeral D' or Signature)
10185
(Registration Number)
Clarence L. Randolph
(Name of Decaaaad)
DOS-1898-f(Rev. 04/20) Page 3 of 3