Daniels, Rickey L Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: rZ co S RETURN TIME: A)a N C
DATE & TIME REMAINS ARRIVED AT CREMATORY: 1130 I&3 Qh
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
mart,‹ Off r tiOt .
NAME: elneel Lrs' CASE # (0Z
TYPE OF CONTAINER: 9'cAL D era ( ( i.y4d
PLACE OF DEATH: &it,T CA l` S
ESTIMATED WEIGHT OF REMAINS & CONTAINER I P1.�) iL
PLACED IN HOLD: D
PLACED IN REFRIGERATION: 2 1411
11
DATE OF CREMATION: I I 3I I Z3
TIME STARTED: II °() TIME COMPLETED: I So fi
PLACED IN RETORT: Ot All MOVED: 12 ys P1fl /=t5iPm
RETORT# IN WHICH REMAINS WERE CREMATED: -Power FAQ t
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.
.1
New York State
Department of State
NEW YORK Division of DIVISION OF CEMETERIES
STATE OF One Commerce Plaza
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: 01/29/2023 Case Number(for crematory use only): I 0 ?-
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, including dental work and implants,will be disposed of as permitted 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: Rickey L. Daniels Marital Status: Never Married
Last Known Address:16 Platt Street, Glens Falls, NY 12801
Place of Death:Glens Falls Hospital, 100 Park Street, Glens Falls, NY 12801
Gender: 1=11 M ❑F ❑X Age: 61 DOB: 04/06/1961 Date of Death: 01/28/2023 Estimated Weight: T
Description of casket/container in which remains will be delivered,including manufacturer or supplier and material.
Buffalo Casket Corrugated Cardboard
PERSON IN CONTROL OF DISPOSITION
(Person(s)in control of disposition, initial ONE of the following)
/We are the designated agent of the deceased designated in a will or written instrument executed pursuant to Public
Healt w Section 4201.
/-OR-
5� I/We ha no knowledge that the deceased executed a written instrument pursuant to Public Health Law Section 4201 or
a wil, ntaining 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: Daughter
DOS-1898-f(Rev. 01/23) Page 1 of 3
Authorization for Cremation and Disposition
(Insert from the list below)
Number: 3 Description: Child
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
Law Section 4201(7).
For numbers 3, 5 and 7 above, by signing,the person(s)signing this Authorization Form represent that they are signing on behalf of a
-liiialo ' f the members of this class of persons who are reasonably available.
(Initial BOT of the following)
Ire hereby affirm that the body of the deceased does not contain a battery,battery pack, power cell, radioactive implant,
6r radioactive device and that any such materials were removed prior to the execution of this Authorization Form. Failure
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...- o remove these items prior to cremation may result in harm to the crematory and crematory personnel.
-�_{� Ire affirm that instructions have been given to Robert Barbieri
`\, ) / (Funeral Director Name)
,fegarding 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 Crematorium
(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.
(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 final resting place for the cremated remains of the deceased is
Return to family
If the funeral director whose signature appears on page three of this Authorization Form is not the person authorized to receive the
cremated remains of the deceased from the crematory,provide contact information for that person or persons:
(Name) (Address) (Phone)
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 Regan Denny Stafford Funeral Home by delivery in
(Funeral Home Name)
in person or via delivery by the United States Postal Service,as permitted by its regulations and procedures.
DOS-1898-f(Rev.01/23) Page 2 of 3
Authorization for Cremation and Disposition
(Initial the ollowing)
i/We 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)
I/We have provided with an urn to be used as a container for the cremated
(Name of Crematory)
remains.The urn 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.
3) e have not provided an urn to be used as a container for the cremated remains, and understand that
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)
Regan Denny Stafford Funeral Home
(Funeral Home Name)
53 Quaker 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.
I/We 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 hereby authorize(s)to cremate the remains of the
deceased.
Signed this 29th day of January 20 23
Sonya Daniels
Typed or Printed Name na
28 Saratoga Ave, Mechanicville, NY 12118-
Address
Typed or Printed Name Signature
Address
Typed or Printed Name Signature
Address
WITNESS:
Robert Barbieri f/ /
(Funeral Director T or Printed Name) (Funeral DiieCto ignature)YPed
10185
(Registration Number)
DOS-1898-f(Rev. 01/23) Page 3 of 3