Neville, Patricia Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: efw RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: I /)°I /3 it ion
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
• yeti M
NAME: FA i CNuZ N fOuj/ CASE # 11
TYPE OF CONTAINER: PIA(OUAI,P (Af�l 2 (a, 44& AND
/AfOesoA
PLACE OF DEATH: 6(1^s fi(IS }(e + t f
ESTIMATED WEIGHT OF REMAINS & CONTAINER 1 Z 0 IL- 5(4,4
PLACED IN HOLD: at re
PLACED IN REFRIGERATION:
DATE OF CREMATION: ) )30 0
TIME STARTED: 12 6S- in TIME COMPLETED: 2.a D sn
p
PLACED IN RETORT: kbO MOVED: 6 v i n 2•io 't
RETORT# IN WHICH REMAINS WERE CREMATED: wEa Pk(sr
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 of State
rr-INEW 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.
1/28/23 Date: Case Number(for crematory use only): 1 i
Pine View Crematory
Crematory Name:
Quaker Road, Queensbury, NY 12804 518-745-4477
Address: Phone:
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
Patricia Neville Married
Name of Deceased: Marital Status:
16 Lawrence St., Lake Luzerne, NY 12846
Last Known Address:
Glens Falls Hospital, 100 Park St., Glens Falls, NY 12801
Place of Death:
Gender: r M x Age:72 :12/21/1950 1/27/2023 120
0 0 F Q X DOB. Date of Death: Estimated Weight:
Description of casket/container in which remains will be delivered, including manufacturer or supplier and material.
mAc PiLD (RywUxt0 . ua( aro Coo6�
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.
-Off
.• I/We 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 relationship
to the deceased is as follows:
DOS-1898-f(Rev.01/23) Page 1 of 3
Authorization for Cremation and Disposition
zIir. 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 of Crematory)
an irretrievable manner, such as by scattering.
CREMATION CONTAINER/URN
(Initial ONE of the following)
I/We have provided Pine View Crematory 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.
O
I/We have not provided an urn to be used as a container for the cremated remains, and understand that
Pine View Crematory
will place the cremated remains in
(Name of Crematory)
a rigid temporary container for delivery.
Patricia Miller
This Authorization Form was provided by was executed at
(Funeral Director Name)
Brewer Funeral Home, Inc.
(Funeral Home Name)
24 Church St., PO Box 500, Lake Luzerne, NY 12846
(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 28 day of January 20 23
Andrew Neville /�i
Typed or Printed Name ignature y
�'�
PO Box 156, Lake Luzerne, NY 12846
Address
Typed or Printed Name Signature
Address
Typed or Printed Name Signature
Address
WITNESS:
Patricia Miller PrAltatjzA
(Funeral Director Typed or Printed Name) (Funeral Director Signature)
12465
(Registration Number)
DOS-1898-f(Rev. 01/23) Page 3 of 3