Vargas, Hector 10F
Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: ��to RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: 3113 ID 2=IOf t/
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
srAza AIroui
NAME: f ftwe_ U ARGiA 5 CASE # ` 0
TYPE OF CONTAINER: 5'tlo-tn,et®ie lig avolft-P $
PLACE OF DEATH: 110 1Aatte60 5 Cli IV'AGti IZ80j
ESTIMATED WEIGHT OF REMAINS & CONTAINER NO Ih .
PLACED IN HOLD: 2
PLACED IN REFRIGERATION:
DATE OF CREMATION: 3/14 (Zg
TIME STARTED: kcc TIME COMPLETED:
PLACED IN RETORT: " 4 1 MOVED: 2.1 S Qn 2-1Set?
RETORT# IN WHICH REMAINS WERE CREMATED: f'o <, PAY V
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
ti_ NEW YORK I Division of DepartmentM T RIES
STATE OF DIVISION OF CEMETERIES
Oi'PORTUNITY_ Cemeteries One Comment Plain
1�FaL�, !9 Washington Avenue
Albany,NY 12231-0001
Telephone.(S18,4746226
www.dos ny.gev
Authorization for Cremation and Disposition
This Authorization Form must be completed and signed prior to delivery of remains for cremation,
Dian?: 2 A� ��,r Case Number(for crematory use only) 7 Lot
Crematory Name Pine View Crematory
Address: Quaker Road, QUOensbury, New York 12804 Phone' (518) 745-4477
I CREMATION IS AN iRREVERSIBLE AND FINAL PROCESS.
I Crerrtatibn is carried out by plating the remains of the deoti ased 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►netal,
which are all that will be left after cremation.
FoiloWing cretrnathon, the i rernatory will take reasonable efftrts to re riove all of the remains and other material from the cremation
chamber,but 5drtie minimal dual and residue will likely be left behind. The crematory will separate incidental and foreign material from
the remains and the incidents#and foreign material, including dental wOrk and implants,will be dispose@ of es permitted by law. The
srernat€d remains will be mechanically pulverized Irate Well pieces and placed inte a designated Container or urn. Cremated remains
generally are pulverized until no single fragment it recognizable as skeletal tissue.
OPENING OF THE CONTAINER
The a r@mattiry may Only Open the container holding the un-cremated human remains in litnited circumstances, suth as to confirm the
identity Of the detested Or to ensure that no material is enclosed which might injure employees Or derniege 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
1
Name of Deceased. /i_'t-,i<L'.. . .4 r,- _ Marital status: /..'
Last Known Address 1,7 /t_' =- $!7 4(, .) 1,,J�f l_ ,,.( / i--
Place of Death l k F1 e.r - ,J` . '�ii�:n-�_ l ��j _�J+V /, -�� /
t
Gender M A F Q X Ages-il Deg- =t0lt f// _ Date Of Death: /lie- ? Estimated Weight: I yU
bescriptibn of casket/tontainer in which remains will be delivered, including manufacturer Or supplier and material.
5-tc31-m6c Cott ecl-mi 5X -1cdt) #- 3
PERSON IN CONTROL OF DISPOSITION
(15 i'a (a)in confibl Of disposltion,initial ONE of the following)
I am/We are the designated agent of the deceased designated in a will or written instrurtlent executed pursuant to Public
Health Lew Section 4201.
-0/?-
I,We have no knowiedge that the deceased executed a written Instrument pursuant tb Public Health Law Section 4201 or
a will containing directions far the dispOSition of his or her remains and Ilwe are the person(,)having priority udder Public
Health Law Section 4201 and have the right to authorise& rfiatien of the remains of the deceased My/Our relationship
to the deceased is as foliews•
DOS-1898=f(Rev. 01/23) Page 1 of 3
•
Hutnonzanion tar Cremation and Disposition
(Insert from the fist below)
Number: 5 Description:
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 persons)eighteen years Of age or older entitled to share in the estate and who isiare closest in relationship to the deceased,
6. A duty 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:
1013. Any other person who is acting on behalf Of the deceased end 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 Farm represent that they are Signing tin behalf of a
majority Of the members of this class of persons Who are reasonably available.
(initial BOTH of the following)
'tC INVe htsreby affirm that the body Of the deceased does not contain a battery,battery pack, power cell;rAditaebtive ifirptant,
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.
_ lNVe affirm that instructions have been given to _ _C.Cj tQ__ . caffe' r t
,n1YrrODiirscf&• ohm,
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. W._Y 1 ,mil_4,t G ,±b r-Lt
(G.en,ahvy Hume) i
_„
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 arid cannot be retrieved
after cremation.
final/el OPTIONAL)
i!we hereby authorize the named funeral director to provide for delivery to and cremation by an alternate
Crematory,if deemed necessary in the opiniftn of the funeral director, and to amend this form to provide the
correct name and address of such alternate crematory.
FINAL DISPOSILTION
The final resting place for the cremated remains of the deceased is
To Be Deterftlime€i Ms.Aida Sanchez
22 Blackwell Ln.
Stony Brook, NY 11790
If the funeral director whose signature appears on page three of this Authorization Form is not the person authorized to receive the
Cremated remeirS Of the defeated froth the crematory,Provide contact infofiritition for that person or persons'
Nacre; dtlecessi
If for Any reason the person reamed above does not take pOSSession of the cremated remains.
Pine View Crertiatory is authorized to give possession of
(Crematory Name)
the remains to Baker Funeral Home by delivery in
Tune,*Mime Names
in person Or vie delivery by the United States Postal Service, es permitted by Its regulations and procedures.
DOS-1890-f(Rev.01/23) Page 2 of 3
Authorization for Cremation and Disposition
(Ini ,; the following)
• _ I/We understand that if the remains are not claimed within 120 days of crematio
n,
on,
Pine View Crematory
rxame cv c emaro y, may dispose of the remains in
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 o'crernaicy,
remains. The urn is described as follows:
- _ Wie understand that if the urn is too small lb hold the entire cremated remains, an additional rigid container may be used
for delivery
-OR-
./We have not provided an urn to be used as a container for the cremated remains, and understand that
pine View Crematory
(Name e!LY6 nalery, will place the Cremated remains in
a rigid temporary container for delivery.
This Authorization Form was provided by Ca_asia Rafferty t114100
_ _ was executed at
(Pudegd C>E'fsr NYa,,ke'
Baker Funeral Home
(Fvih 1 Home Nehra:
11 Lafayette StrOet, Quecnabury, New York 12804
iC.mtrat Rbroe Add•eC,, _
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 Wore the person(s)in central of disposition,who by signing this Authorisation Form, attest(s)to the accuracy and
cornpieteness of the information contained In this Authorization corm and hereby authorizes)to cremate the remains of the
deceased.
Signed this I day of V(OIL , 20_ -S.
tl� Sa� ch�e �
POor Pyi+itez Name/► LILLV
Adores
__
Typed or Pnnled xamf
Addr655
WITNESS:
Caste Rafferty 4 ��f
(Funeral Drecer Typed d Ph-n Nar•el -.. �""�'��""" jaw
l�unpra, ,redc-Sgnalu•e) i
Funeral Home Reg. N01130
I eg fra! .1Von71,6, - - --. -
DOS-1898-f(Rev, 01,23;
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