Rapant, Frank Jr. Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: kett,4 RETURN TIME: U& D fr-
DATE & TIME REMAINS ARRIVED AT CREMATORY: 31 h 173 I Teri
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
WI rEl
NAME: FaANK FAC19f\for CASE # z I�
TYPE OF CONTAINER: Flo ricix E. c'e4141T�4'� u 1Z NF.p
11.Nk.' [V\RoDiotZ
PLACE OF DEATH: 11Z 5 ke IL( R I.,c�1 iv,,AL �+-0( t_ (7.153
ESTIMATED WEIGHT OF REMAINS & CONTAINER f co l L sr
PLACED IN HOLD:
PLACED IN REFRIGERATION: I ' cc C h
DATE OF CREMATION: 31$ I
TIME STARTED: t=y>s TIME COMPLETED: Dicrn
PLACED IN RETORT: g'bt) !I' 1 MOVED: g'yD 4n� (/
ifn
RETORT# IN WHICH REMAINS WERE CREMATED: Z O J, le
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
TX-NEW YORKDIVISION OF CEMETERIES
STATE OF DivisionOf
OPPORTUNITY. One Commerce Plaza •
' 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: 311 113 Case Number(for crematory use only): 217
Crematory Name: Pine View Crematory •
•
Address: S1 QuakPr Rna 1 QtiPPnsbury, NY 12801 Phone: 51 8-745-4477
•
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 arid 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•wiil likely be left behind. The crematory will separate incidental and foreign material from
• • the remains and the incidental and fgreign 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: Fl/I/i!K 1?A 1 x) . • • • Marital Status: 1J1 vc re-
Last Known Address: _33 au d- o&, ( /k t t— ► ct /lees.,C,0Pal.�j orr, .
• Place of Death: lde rwc,o 4 of 4tJarlli t e e-K /Ia 5 K/ t;Qri/ gd •Itie r j c L' /Yp 42 1(5 3
Gender: ElF El X. Age: 9... DOB; C 9/a f i fa 9 Date of Death:65 3/ 6//20 3 Estimated Weight; ACC)
• Description of casket/containerco�aa in which remains will be delivered,including manufacturer or supplier and material..
r_1oIA )cL eJ-e rvr/t/'OV ()41 i ipi/L' e_
PERSON IN CONTROL OF DISPOSITION •
(Person(s)in control of disposition,initial ONE of the following) •
• /We a designated agen a e pursuan o
Hee Law Sec
-OR- • •
i—. • 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:
DOS71898 f(Rev.01/23) • Page 1 of 3
Authorization for Cremation and Disposition
(Insert from list below)
Number: 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 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 reasonablyavailable.
(Initial BOTH of the following)
CC
I/We 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 nd crematory personnel.
II/We affirm that instructions have been given to 4'L, �� ?✓��
nerel Director Name)
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. Pine View Crematory•
(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) • .
I/we 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 •
.�e,Tu r>v Th 7 i r1 FArw7" I-0r Q1 s pe 5;1i c►�-�
•
•
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 Crematory is authorized to give possession of•
, (Crematory Name) • .
the remains to 60,4 re - /��/// Fu Joe r A I /4 0 m'`�- by delivery in
(Fun rel 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 following)
t9 ? 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 CONTAINERIURN
(Initial ONE of the following)
e ave f e with an to ha r i ed + r ahe__
(Name of Crematory)
remains.The urn is described as follows: •
I/We unders_ls4 that if the ur ' ,
for delivery.
-OR
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. /
This Authorization Form was provided by L dlu ..-� // was executed at
9 rr li (Funeral Dlred r ama)
C c tdid 14 1\ l�e j F u 1 r r/ ,� lll!
r73J —
PG y 51- /019 US �z 12y 19-8'7o
(Funeral Nome 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,attests)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 7-0 day of /VA r(it 20 _.• ' •
Frn tv gA A u r VT-
Typed or Printed Name Signature
,517 •Popovaer RA 0-P,V1e..ra ).�,Y', /ad13
Address
Typed or Printed Name Signature •
Address
Typed or Printed Name Signature •
Address
WITNESS: /
(Funeral±0rTyped or Printed Name)/Y (Funeral Signature)
( e9sVR f lion Nu
DOS-1898-f(Rev.01/23) Page 3 of 3