Stearns, John L Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: �� �n
RETURN TIME:
DATE 8 TIME REMAINS ARRIVED AT CREMATORY:
NAME OF FUNERAL DIRECTOR OR LI (?� I 73
REGRISTERED RESIDENT DELIVERING REMAINS:
NAME: /0 5'r t fr — —
CASE # 3-)o
TYPE OF CONTAINER: it') R
SOs
PLACE OF DEATH: C!� •r5(IS
,s fry
ESTIMATED WEIGHT OF REMAINS & CONTAINER
� 5�� 175 l41scd�
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION:
I_ Z
TIME STARTED: Zz 7 TIME COMPLETED: 1 Zu ph
PLACED IN RETORT: " MOVED: /7 `IS :0(S' r
RETORT# IN WHICH REMAINS WERE CREMATED:
PAK
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 Stet*
NAEW�YORK Division of D
OPPORTUNITY.for'f—is-TOne Commerce Meta
Cemeteries y. 1
Telephone:4519,4744226
www.deany.gew
Authorization for Cremation and Disposition
This Authorization Form must be completed and signed prior to delivery of remains for cremation.
Date: Li 17417,5 Case Number(for crematory use only): 3 7 a
Crematory Name: Pine View Crematory
Address: Quaker Road,Queensbury, New York 12804 per: (518)7454477
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 loft after cremation.
FOIOVANI cremation,the crematory will take reasonable efforts to remove all of the remains and other material from the cremaSon
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 taw• The
cremated remains will be mechanically pulverized into small pieces and placed into a designated container or urn. Cremated rummies
generally are pulverized until no single fragment is recognizable as skeletal tissue.
OPENING OF THE CONTAINER
:The may only open the container holding the un-cremated human remains in limited circumstances,such as to(=San tide
Identity of the deceased or to ensure that no material is enclosed which might injure employees or damage the crematory properly. I
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 reap to
IDENTIFICATION OF DECEASED
tiiame`of Deceased: 1� (1 L• C\ SStatus: AlP site", 14a,
k
Marital
Laid Known Address: I 7C) ()Ho
' li !se( Fn X Age`7D DOB: 5-1 2 Z Hate of Death' y'Zo 1013 Esrirrneied Weight r
r sleet cordakar in which remains willdi be deNveied,inducing manufacturer or supplier and material.
ar L 0 ar& rcl Pan x " 388 CO
CONTROLCOOL OF DISPOSON
t )hi: of disposition,Initial ONE of the following]
.�..---. aiTiMfe are the designated agent of the deceased designated in a wIN or written insfrume nt exec ubtod pursuant to Pi**
Heath Law Section 4201.
w ;
Me have no knowledge that the deceased executed a written instrument pub to Pubic Health taw Saon, fir.
s w I containing directions for the disposition of his or her remains and ilwe are the person(s)having pitotity UMW PWII
Neagh Law Section 4201 and have the right to authorize cremation of the remains of the deceased. Myloaer
to the deceased is as follows:
x O tom.011 Pao. silt
ton _for Cremation an..:aiseositio:0::-*,:i1:1:'.'' _ .__ _ .
•::::!4---:::-:.--if.-i-_,.„--:'----.,:-...-- —71:000$0 c--,- '--.-
Descr •ptio,,; vs�Q f
opkosis&
person►designated in writing pursuant to
Al Public Health Law, ecn'42b1(3);
u
` .s�..one parttrer; - =
'Any sulti� b ►pars ofage:or cider,
�; r peer . .
-` , ,� "' ," !W.eighteen years of age or older, ,
ated
I� .. i ,
iiT. r y ", s ." years of age or older entitled to share in the estate and who Taro closest roa#ions;<�the .
: lducdiry of the estate;
'� of relative who.has executed;a}.writtten statement pursuant to Pubic Health Law'Section 4201(7);
-- s .
,;{.,, r ' , ,otRb�r, -,s cpu---.. r a pudso administrator appointed pursuant to the Sumo�te�s Court Prn
person w1ho is acting on behalf of the deceased and who has executed a written sta ment pfrsuantffi� am►
r. 0)1
by= 1,the t s 3 g Authorization Form represent that they ar -;..an, i
k, tofitl of the members of this class of persons who are reasonably available.
erlgtePAowlr+pi
• ,) • 4 ``
v
afflrrrr O ahe body of the deceasad,doas not contain a battery,battery-pack,power
,e t orwe device andahat any such►materials ware removed prior to the execution of this ' -,
rslaiove thsss tr pi r to cremation rresult.In:harm to the an coda ' fr -_
L
.� . .fANe attirta that have'been g rtt0 -- .. , ,. , 1 0. t!, _ i .t :''' '' 0 ''- ,
regarding:aaec+ aaal aeq pawl.pnoperiy or other thing of value whichark►Pelt si r , " u
i . erpeer of the deoe to erva i + -
r
.,. -is' t theremoval of personal Items"from tainer or from the remains of the , k z
� '' ° s Or with t r mall is will•be d� by the•crxtntation proses:and E
l 4; 4 x .
< - "'1 r J clef . . t t ..-'`t,.k - ?s D r.
S named A gal director to p for de8riry ..............................
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oclzation for Cremation and Disposition
� .° Me understand that N the remains are not claimed within 120 days of cremation. ,--`•7
Pine View Crematory - dispose,dUie ti->'a°- ` ,-" *,
paw otenonsiem
Yrt'±"• 'eninetrtevabie manner,such as by scattering.
;: ORMajcitt&Singtegangt :. ,
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,; '-`/4:4 -'!'' e he" Pine View Cremato fiot ttte -.u-,:, !,,<,:,_
K �ryy -provided-, rY with an um to be used as s`co-rrtshie ,` ,•z ,,
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