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Spinelli, Jane J Pine View Cemetery & Crematorium Quaker Road Queensbury, NY 12804 (518) 745-4477 or (518) 745-4476 FUNERAL HOME: / 7/ RETURN TIME: ,,0( DATE & TIME REMAINS ARRIVED AT CREMATORY: /2 J /Z-Z%Z z Z NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS: Zorn- C/ewc /a,a NAME: T3 L r\l CASE # I U 33 TYPE OF CONTAINER: 4- 1,9 re) ' Creima j:D) Co i- 4 el)ex /� PLACE OF DEATH: a7 79 (e..J- ,_r 1� I),,cJ) L1,✓y /2 9,'/ ESTIMATED WEIGHT OF REMAINS & CONTAINER /0 0/6 5 / 30 JLcy� PLACED IN HOLD: PLACED IN REFRIGERATION: /Zi,._ DATE OF CREMATION: /2-30_Zo Z Z. TIME STARTED: 7l,,,1 TIME COMPLETED: I 00- PLACED IN RETORT: f p- MOVED: g itr--- ^D RETORT# IN WHICH REMAINS WERE CREMATED: Pouh.r JC 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. 01/12/2013 21:46 5185327177 ELKFUNERALHOME PAGE 02/04 New York State • TY-NEWYORK Division of DepartmentofSIESe DIVISION OF CEMETERIES STATE OF one Commerce Plaza OPPORTUNITY. Cemeteries 99 Washington Avenue Albany.NY 12231.0001 Telephone:(5113)474-6226 www.doB.ny gov Authorization for Cremation and Disposition This Authorization Form must be completed and signed prior to delivery of remains for cremation. Date; IL 12' (la Number. • 1°• :3 Crematory Name:Pine View Crematory , Address: 71 0vOra- R0120 iiikre F.4so fj 41, _.Phone: S )9 ~-r1 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 chamberwhere they are subjected to intense heat and tame. 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 ditto remains and other material from the cremation chamber,but some! iOmai Gust and residue will likely be left behind The crematory will separate incidental and foreign material from the remains and the incidental and foreign malarial 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 le recognizable as skeletal tissue_ OPENINQOF THE CONTA1NE 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 orthe 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: ekel e- /�S2 I Aire //i mania!Status: N'i"N 7 411-- Last Known Address: 1419 e,e4u k r- .L inD t AA eNxr N•7' / X 7 a O d Place of Death: 71 7 ee-Lo�P I•-. /-Zc� Ma I"%A-1 "est/jTe4- N% I a-7G p Sex: 0 M J-Age: 874 D08:/1.la 0 935 Date of Death /al a-q/a0a1- Estimated Weight /04/4s Oescri •' n of casket/container in which remains will be delivered. —,-, .v.._ ehempz. PERSON IN comour DISPOSITION (Pelson( " control of disposition,Initlel ONE of e following) t anti re the des' t ere of the designated in uarrt m uOF"— He Scout 4201. 26....-0R- cip Wee 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: Zi N e•-• -Se 1 Ai l/! Mame DOS-1898-f(Rev.08115) Page 1 of 3 01/12/2013 21:46 5185327177 ELKFUNERALHOME PAGE 03/04 J Authorization for Cremation and Disposition (Insert from the list below) Number:. 9 Description: CIO Se. Rt-l14 [Jilk 1. Nj?e�*--� 1. A person designated in writing pursuant to Public Health Law Section 4201(3); 2. The ouMving 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 Iawhdly appointed guardian; Any yperson(s�fiduciaryn e age of the �older entitled to share In the estate and who Ware closest in relationship to the deceased; 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 ailing on behalf of the deceased and who has.executed a written statement pursuant to Public Health Law Section 4201(7). ilia!ALL THREE of the fallowing) i37 )(.. .IMIe hereby affirm that the body of the d does not contain a b battery pack,power cell,radioactive implant. or radioactive device and that any such materials were removed prior to the execution of this AuBronaafton Form. Failure to remove these items prior to cremation may result In harm to the crematory and crematory personnel. .1.---: ( . K 1Ntle affirm that instructions have been given to �!�!�/Nl �-1 ' 1�1 (F regarding the removal of any personal property or other thing of value which any person signing below or any famiy member of the deceased wishes to preserve. Pine View Crematory armatow Nine) is not responsible for the removal of personal items from the Container or from the remains of the deceased. Personal Herne left In the container or with the remains will be destroyed by the cremation process and cannot be retrieved after cremation. 6\� M Wile hereby authorize Pine View Crematory gremErowomor • 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 1019 US RL 9 PO Box 548,Sdmroon Lake,NY 12870 Address: Phone:518-532-7177 The cremated remains of deceased will be disposed of es follows: .71.1-11r-i-4.4, S..12_,fit rA ile_g- ee-r1-0-7—eix Sipiii) Lib fixiii 1,07; 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 rcnimselyeame the remains to_Edward L Kelly Funeral Home by delivery ffim WtiomoNema) in person or by registered mail. J-14 N �`/'�d�meofo4e�l Page 2of3 DOS-1898-f(Rev_08f15) 01./12/2013 21:46 5185327177 ELKFUNERALHOME PAGE 04/04 Authorization for Cremation and Disposition (Initial the following) IN1le understand that if the remains are not claimed within 120 days of cremation, Pine View Crematory may dispose of the remains in omm orcRm iwo an irretrievable manner,such as by scattering. CREMATION CQNTAINERtURN lkeial ONE of the following) b- a sad as a ta" r the as :tins has puroha m e om an• is d= cribed =. •lows: I derstand that if the urn is too small to hold the e cremated remains,an additional rigid container may be used for delivery. -0:- �"S % An urn Is not yet purchased. UWe understand that if no urn is purchased or otherwise provided /,j f�, Vic iJ eir-12 f,i ro 1 v/ will place the cremated remains in awilearawKamo a rigid temporary container for delivery. �� This Authorization Form was provided by r- '3 h' 1.. _#. 't/( 'V was executed at Qiaaae�la6e�erName) L Edward L Kelly Funeral Home 1019 US Rt.9, PO Box SOSchroon Lake,NY 12870 ( aarNomemane (Fmsaal bonze AddaBR) and is signed by the funeral director as witness to its execution. I/We have received a completed copy of this Authorization Form. The peraon(s)identified below islare the person(s)in controFof disposition,who by signing this Auth on Form,attest(e) to the accuracy and completeness of the information contained in this Authorized / nd a the ing. � Si d this Q A day of ;2.0 _ ''� 4_5 -* Ueborack 1 ve.L; J a „ ✓w* \1' --J-6w ie N j o- 13pedor Ponied Mune 9gaaal m Moen 'ypedorPrinted Name 84neitea AoSes • -Z° et) 4r. (Fume+Dencr riyyecrorPfaisdNana) os 19 u e' 30g24/0-ei��-2� Page 3 of 3 DOS-1898-f(Rev.08115)