Graves, Candy Sue a
Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: �►�" e I, ,\J RETURN TIME: i✓/ C_
DATE & TIME REMAINS ARRIVED AT CREMATORY: /1Yn4.
-Zv2 3
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
9 l� 7a_K. S [n_
NAME: nAic-1 Cnet (1e CASE # �v
TYPE OF CONTAINER: �����e,�)J �'� );p,,� (4.�PT ��,-c1 POev-rt 4-0 A)
vl/�Q L' L 440 m
PLACE OF DEATH: (4p5J , (' 'e k c, _ 3c2 "J. I '
/Z /U
ESTIMATED WEIGHT OF REMAINS & CONTAINER 23 /L 5
PLACED IN HOLD: /Z
PLACED IN REFRIGERATION:
DATE OF CREMATION: 1-7- ZaZ 3
TIME STARTED: ,`
TIME COMPLETED: 3 �,;N.•
PLACED IN RETORT: 1-irr^- MOVED: ZP— Zc
RETORT # IN WHICH REMAINS WERE CREMATED: 3t.fec Paves`-
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 Stele
Department of State
NEM: C t s
YORK
.......
Division of
emeerie
DIVISION OF CEMETERIES
STATE OF
One Commerce Piaze
OPPORTUNITY.
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:1/5/2023 Number: . .
Crematory Name:Pine View Crematorium
Address:Quaker Rd., 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
Candy Sue Graves Single
Name of Deceased: Marital Status:
4112 US Route 9 Warrensburg,NY 12010
Last Known Address:
Place of Death:
Capstone Rehab 302 Swart Hill Rd,Amsterdam,NY 12010 .
Sex: 0 M E3 F Age:64 DOB: 05/15/1958 Date of Death;01/04/2023 Estimated Weight:
250
Description of casket/container in which remains will be delivered.
Matthews Cremation Case, Cardboard Top, Wood Bottom
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.
-OR- A
lANe have no knowledge that the deceased executed a written instrument pursuant to Public Health Law Section 4201 or a
will con aining 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:
Candy Sue Graves .
(Name of Oeceased) ^---- .
DOS-1898-f(Rev.04120) Page 1 of 3
Authorization for Cremation and Disposition
(Insert from the list below)
niece
Number; 6
Description:
1: A perion 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 cider;
4. " A surviving parent;
5. A surviving sibling eighteen years of age or ader;
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 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).
(Ini a! L THi(EE of the following)
Me 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 ' ms prior to cremation may result in harm to the crematory and crematory personnel.
Twoll4L
e affirm that instructions have been Oven to Mark K. Parish
(Funeral Dirac(Of Nettle)
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 Crematonum
deceased wishes to preserve.
(Crania/ay 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
co a' er r with the remains will be destroyed by the cremation process and cannot be retrieved after cremation.
I1
Pine View Crematorium
e hereby authorize
(Crema(ory Name)
to cremate the remains of the deceased.
InUiai OPTIONAL)
Ifwe 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:Carleton Funeral Home, Inc,
Address:68 Main St., Hudson Falls, New York 12839 Phone: 5187474243
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
( reeekey N one)
the remains to Carleton Funeral Home, Inc. by delivery
(Funeral Home Name)
in person or by registered mall. Candy Sue Graves
(Name of Deceased)
Page 2 of 3
DOS-1898-f(Rev.04/20)
Authorization for Cremation and Disposition
flwing
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 Cremato(Y)
an irretrievable manner,such as by scattering.
CREMATION CONTAINER/URN
(Initial ONE of the following)
Ah 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.
-0
IA1 ;44
An urn is not yet purchased. I/We understand that if rio urn is purchased or otherwise provided
Pine view Crematorium will place the cremated remains in
(Name of Cremator")
a rigid temporary container for delivery.
This Authorization Form was provided by Mark K. Parish was executed at
(Funeral Director Name)
Carleton Funeral Home,Inc.
IFttneral Home Name)
68 Main St.,Hudson Falls,New York 12839
(Funerat Home AdireSS)
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.
5th day of January 23
Signed this ,20 • „,
Sherry Rozeli -
TYPed or PrMred Weal*
94 Pultney St,Whitehall,NY 12887
Ao;ass
ryped or efinie0 Name Si7fWure
Adorns
rjrACI Cr Printed Neme Stralttre
WITNESS:
Mark K. Parish
(Funer)Onclor Typi;or Primed Name) Lerat Direc.fOr S4na(ufe)
12782
(pagisimi,on
Candy Sue Graves
(Name of Deceasec0
DOS-1898-f(Rev.04/20) Page 3 of 3