Meahan, Geraldine J /:4J)
Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: rE.(,i,4 RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: 21 Z 11/3 9 , 01111
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
q't)14,4 �° LC
NAME: 41A tUxN'F_ NL W A 0 CASE # I I S-
TYPE OF CONTAINER: D itrAgO)CE (PI-SW OT (J . Frn)E /t to
PLACE OF DEATH: 1 DELii/WP AT NO C► '2E K
Pd1IZ�SI
ESTIMATED WEIGHT OF REMAINS & CONTAINER Igo iir
PLACED IN HOLD:
PLACED IN REFRIGERATION: l :oo
DATE OF CREMATION: 2 1 3 J Z_3
TIME STARTED: 7,30 1 TIME COMPLETED: 10 L/O
PLACED IN RETORT: g'bp61 MOVED: 9 is Aril 91Sm1 ,
RETORT# IN WHICH REMAINS WERE CREMATED: FRi(n. 10 i0
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
rriNEW YORK Division of DIVISION OF CEMETERIES
STATE OF One Commerce Plaza
>�l OPPORTUNITY_ s er Cemetie 99 Washington Avenue
Cemeteries 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: 21 Z I"Z3 Case Number(for crematory use only): II
Crematory Name: QZN yew CriFilyT0(t LtA)
Address: 71 OvRILLam. [ipA()1 QtAi ,IEoce l ak , 17011 Phone: 63-) -MS-'IhT)
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: 6 a rift i dt toe, W , . Ple e,4cr) Marital Status:/ kJ ``4,—
Last Known Address: •�{o'S' /Y ri R ' rn/Al ✓e� 1 A9 fir. / acpS'" L
Place of Death: p f d e,- t 0 od- Kr- 100 r- Lei--e-0-1( /C. 7I ei-Q-e./� t' i ' 17 13
Gender Ill [iF❑X Age: 3.5--DOB: B A /1 S ! !q�1 Date of Death:Ofr /--d-Q Estimated Weight /�'
Description of casket/container in which remains will be delivered, including manufacturer or supplier and material.
t. /'f-ei;(A_ eN-m A 11 CP op-tA jive',r---' (YIP A;to
PERSON IN CONTROL OF DISPOSITION
(Person(s)in control of disposition, initial ONE of the following)
mNV the ignated he dec desi i or s rument ex uan to Public
Heal aw Section 42 .
Ii► k
:r4J1, 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:
bet.-,, 0,,,„42-
DOS-1898-f(Rev. 01/23) Page 1 of 3
Authorization for Cremation and Disposition
(Insert from Irst below) I �� I .
I
Number: Description: 0r v'AJ �4/ d
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
majority of the members of this class of persons who are reasonably available.
(Initial BOTH of the following)
YCA. I/We hereby affirm that the body of the deceased does dot contain a battery, battery pack, power cell, radioactive implant,
or radioactive device and that any such materials were removecr prior to the execution of this Authorization Form. Failure
to remove these items prior to cremation may result in harm to the crematory an- c atory personnel.
4A\I/We affirm that instructions have been given to c 4/� C ` l/
(Funeral Direct Name)
regarding the removal of any personal property or her thing of value which yy person signing below or any family
member of the deceased wishes to preserve. 11uQ v er'eu' t' ,-' sa
—ter V
(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)
Uwe he by au ize amed funeral director to provide for delivery to and cremation by an alternate-
cremato ' deemed neces in th I di , to provide the
rrect name and address of such alternate crematory.
FINAL DISPOSITION
The final resting place for the cremated remains of the deceased i /` A � �$�
,fir-- rn A -)'' C p v►1 ,x. ci, o` e/ )
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,
F1,47.V.I Cv (10 trill TV cti 4 _. is authorized to give possession of
(Crematory Name)
the remains to .0 idiW9 L K f(. 1 by delivery in
(Funeral Home Name)
in person or via delivery by the United States Postal Service, as permitted regulations and procedures.
DOS-1898-f(Rev. 01/23) Cel-illiCti
Page 2 of 3
Authorization for Cremation and Disposition
(Initial th following)_ie underspthat if the re dins are not claim within 120 days of cremation,
- �f? (�( e co rem A lam 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 ha,- pr• •e-. _ p Link) T •_ " = urn to be used a container for the cremated
We of A)
remains.The urn is des •.ed as fo .ws:
e unders d that if the 's a entire cremated remains, an additional rigid container may be used
for delivery.
e have not provided an urn to be used as a container for the cremated remains,and understand that
21JI4/ cEt} will place the cremated remains in
(Name of Crematory)
a rigid temporary container for delivery.
This Authorization Form was provided by 70 FiN 1,11 was executed at
(Funeral Director Name) •
Edward L. Kelly Funeral Home
:Funeral Home Name)
PO Box 548, Schroon Lake, NY 12870
'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.
S' ned this � �� da of (a'ti Pt-v.A' ,20
a,�\.\ten . �rn �-�
`j��
Typ or Printed Nam lure
qIQ \t 1 .�er✓Ck i 2535) I
Address
Typed or Printed Name • Lure
,-- /
Address
Typed or Printed Name Signature
Address
7S:, Ff —14
AO �11 µ—
(Funera�recf� yp_ed�r Printed Name) (Fu hector Signature!
(Regis hon umben .a.---- Plea a-A)
6,FA (di�'
DOS-1898-f(Rev. 01/23) � Page 3 of 3