Loading...
Halterman, Harley Pine View Cemetery & Crematorium Quaker Road Queensbury, NY 12804 (518) 745-4477 or (518) 745-4476 FUNERAL HOME: 1'i RETURN TIME: DATE & TIME REMAINS ARRIVED AT CREMATORY: Z I ZZ I Z3 op f�1 NAME OF FUNERAL DIRECTOR ORREGRISTERED RESIDENT DELIVERING REMAINS: ✓ KuGr f- Li2 NAME: PlilitH 1-t Aurfp 1 CASE # 0° TYPE OF CONTAINER: FCo:Lec,c‘ Cl\swCA- to. ffilzOIol1F.1D PLACE OF DEATH: AcBti1✓1 t PDtLv (- axx- p ESTIMATED WEIGHT OF REMAINS & CONTAINER I it PLACED IN HOLD: PLACED IN REFRIGERATION: DATE OF CREMATION: 712Z, 1 L3 TIME STARTED: 2 Jp ell TIME COMPLETED: 2 LW 7 PLACED IN RETORT: 7,'001 MOVED: 2 3vofl RETORT# IN WHICH REMAINS WERE CREMATED: t PR119-71t 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. J New York State Department of State J1NEWYORK 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. Date:2/12/2023 Case Number(for crematory use only): Crematory Name: Pine View Crematory Address:21Quaker Road, Queensbury, NY 12804 Phone: 518-745-4477 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 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: Harley Halterman Marital Status: Single Last Known Address: 154 Lamplighter Acres Fort Edward is 1 116�� Place of Death:Albany Medical Center Gender: ©M 0 F®X Age:0 DOB:02-14-2023 Date of Death: 02-14-2023 Estimated Weight: 0 Ii Description of casket/container in which remains will be delivered, including manufacturer or supplier and material. Minumum Cremation Casket, Florence Casket Co. Cardboard/Pine 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. -OR- C 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 (Insert from the list below) Number:4 Description: Anysurviving parnet 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) Cl/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 and crematory personnel. C Nr I/We affirm that instructions have been given to 0 (Funeral 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. (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 Given to Cynthia Halterman 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: 136 Main St. South Glens Falls, New York 518-745-8116 (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 M.B. Kilmer Funeral Home by delivery in (Funeral 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) 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) providedPine View Crematory INVe have with an urn to be used as a container for the cremated (Name of Crematory) remains. The urn is described as follows: �/ IcEEP5AKE SNt�(I. Vier 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. -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 Claire C. Konopka was executed at (Funeral Director Name) M.B. Kilmer Funeral Home (Funeral Home Name) 136 Main St. South Glens Falls, New York 12803 (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 21 day of February ,20 23 Cynthia Halterman Typed or Printed Name Sign re 154 Lamplighter Acres Fort Edward New York 12828 Address Typed or Printed Name Signature Address Typed or Printed Name Signature Address WITNESS: Claire C. Konopka C (Funeral Director Typed or Printed Name) (Funeral Director Signature) 11932 (Registration Number) DOS-1898-f(Rev. 01/23) Page 3 of 3