Towers, Nancy (Cm()
Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: NOS+nI E RETURN TIME: (?N'11AT AT.
DATE & TIME REMAINS ARRIVED AT CREMATORY: 2)I y I z3 3.so itti
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
840 PE4SMvC6
NAME: MAtiCi4 M. Td v��r' CASE# / -3
TYPE OF CONTAINER: m.F1T[W 4 fitvfPc f\I R } WMM►0
/;rD ORDftictO.
PLACE OF DEATH: co ra 51'. itio 17 o p,
ESTIMATED WEIGHT OF REMAINS & CONTAINER AO /kr f y9�5c4...
PLACED IN HOLD: $"it
PLACED IN REFRIGERATION:
DATE OF CREMATION: 2/S 2_3
TIME STARTED: 7 TIME COMPLETED:
9 4A
PLACED IN RETORT: �3� MOVED: � p--� �p�'�0"�✓
RETORT# IN WHICH REMAINS WERE CREMATED: t y9 r«
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.
Now York St:+rt,
NEW YORK Division of Department of State
DIYiSlON OF CEMETERIES
STATE OF One Commerce PInzA.
OPPORTUNITY. Cemeteries 99 Washington Averioo
Albany,NY 12231-0001
i zlephone.(518)474-6221k
www,dds.ny goer
Authorization for Cremation and Disposition
This Authorization Form must be completed and signed prior to delivery of remains for cremation.
Date. Feb 13 2023 Number ' �3
Crematory Name:Ptnevlew Crematory.
Address 21 Quaker Road,Queensbury,NY 12804 Phone: (518)745-4477
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Crematon is=Tied 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 fxeign material from I
the remains and the inoderral 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 um. Cremated remains generally are pulverized until no
single fragment is recognizable as skeletal tissue
OPENING OF THE CONTAINER
+*e crematory may only open the container holding the un-cremated human remains in limited circumstances,such as to confirm the
identity of the ceceased 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 Nancy Towers Marital Status'
Last Known Address 90 North Main St,Castfeton-an-Hudson,NY 12033
Place of Death Riverside Nursing Center,90 North Main St.,Castleton-on-Hudson,NY 12033
08l0511951 02/11/2023
Sex Om 51 F Age 71 71 _ DOB: Date of Death; Estimatsd Weight
Description of casket/container in which remains will be delivered
(typelmatenallmodellmanufacturer) Matthews Aurora Wood and Cardboard Cremation Container
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
f ilWe have no knowledge that the deceased executed a written instrument pursuant to Public Health Lax Section 4201 or a
wiii'tontaining directions for the disposition of his or her remains and i/we are the persons)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
Nancy Towers
DOS•1898 f IRev 08115j Page 1 of 3
Authorization for Cremation and Disposition
(insert from the list below)
Number: 3 Description: Surviving Son
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.
S. 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(dose keno 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 mho has executed a written statement pursuant to Public Health
Law Section 4201(7)
0.ia1.ALL THREE of the following)
;( � c` iiWe 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
these items prior to cremation may result In harm to the crematory and crematory personnel.
t -` ttwe affirm that instructions have been given to Robert i.Densmore
(r',maa)bream uam.i
regarding 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
Pineview Crematory
(Crematory Nam,
is not responsibie 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.
ItWe hereby authorize Pineview Crematory
rtMV �, penman Name)
to cremate the remains of the deceased.
FINAL DISPOSJTiON
The person autncxrzed to receive the cremated remains of the deceased from the crematory is
Nacre Robert I Densmore
Address 7 Sherman Avenue.Corinth,NY 12822 Phone(518)854.9285
ire cremated rrrated rerrm;i;rs of deceased will be disposed of as follows
r3rrnai ir,St Marys Cemetery.Corinth
If for any reason the person named above does not take possession of the cremated remains,
P Inev:ew Crimatoraunl
_ • is authorized ,give possession of
C,,.cu err reee tr
the rtrna,rts r Densmore funeral Homes Inc _._._
by delivery
7fi otaa r ltanf N*1,el
in person or by regetered rna,i
Nancy Towers
Page 2 of 3
DO .1898-f(Rev 0 i1-
Authorization for Cremation and Disposition
(Initial the following)
4 Me understand that if the remains are not claimed within 120 days of cremation,
Pineview Crematorium may dispose of the remains in
r ac. y)
an irretrievable manner,such as by scattering
CREMATION CONTAINERftAN
{lniti i ONE of the following'
e, Densmore Funeral Home.Inc
,,,r An um to be used as a container for the cremated remains has been purchased from
and is described as follows Cr G S C.=,�� ^^�� a'Z�
INUe understand that it the urn is too small to hold the entire cremated remains,an additional rigid container may be used for delivery.
-C'
An um is not yet purchased INVe understand that if no urn is purchased or otherwise provided
Pineview Crematorium
_ will place the cremated remains in
Name C,,Crematory;
a cord temporary container for delivery
This Authorization Form was pronded by, Robert I Densmore was executed at
rii...w ciwia Mfine)
Dersriore Funeral Home Inc
(rwgral tqrner Nam
Sherrrsan Ave•nae,Corinth.NY 12822
____ _ mows/realms AObsss)
ano rs s,s..reO by the funeral director as witness to ns execution
:'Ne have receved a completed copy of this Authorization Form
The percents'identified below Istare the persons)in control of disposition,who by signing this Authorizat'on Form,attests)
to the accuracy and completeness of the Information contained In this Authorization Form and authorizes)the foregoing.
lam iSigned this_l �_day of February .20 2023 /J//
CO.t M J J J
;, .arcet.i3 ��. /� '�•__„/J'
1274 Locrtr Road hinder,Ontario,Canada,KOM2K0 i) ____
Fcsaesa.
•Tr;:E+c.-fivpV a"CC i. -M .,�_ _ ___
"� tJtyhap
WITNESS, -
Rr.Mert l Uer.,^Cr a
S ..
-eb;Yk t A r._Cr,
Nancy f°weru
DOS 1E,t9B-`;Rev 'iS Page 3 at
I
1