Flynn, Barbara D LF
Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: h•.CCF
RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: 5-I2 /�3 E710
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
A ��lTl`1 z<<Lfl
NAME: � C �� ------
CASE # 3gl
TYPE OF CONTAINER: k(c9N4(p (ot' tL,
a
PLACE OF DEATH: (12(1 f 5r)11-e P Np I
zakZ
ESTIMATED WEIGHT OF REMAINS & CONTAINER
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION: S'L3 I .L3
TIME STARTED: I2;co Qt'i TIME COMPLETED:
PLACED IN RETORT: I'Ki MOVED: D
RETORT# IN WHICH REMAINS WERE CREMATED: Super ft w2 PAZ
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.
M
n it Yofk 51a1F
IMEW YORKDepartment of State
Division of °�^�ott°FCEMETERIES
er1
STATE OF one Conitne ate Plata
OPPORTUNITY_ 99 Wasngton n Ave -Ic
Cemeteries hi
Albany,niY 12231 0001
Ti.ephOntr,{51a,1474-6226
'ono dos rry.gov
Authorization for Cremation and Disposition
This Authorization Forth must be completed and signed prior to delivery of remains for cremation.
4/330123 3(7
Date: Case Number(for crematory use only):
Fine View Crematory
Crematory Name:
Quaker Road,Oueenabury.NY 12804 518-745-4477
Address: Phone:
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS. •
I 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 metai,i
which are all that will be left after cremation.
Following cremation,the crematory mill take reasonable efforts to remove all of the remains and other material from the cremation
chamber,but some minimal dust and residue wit Likely be left behind The crematory will separate ira.idental and foreign material from i
Me remains and the incidental and'foreign material.including dental work and implants.wit be disposed of as permitted by taw. The
cremated remains will be mechanically pulverized into swat pieces and placed alto a designated container or urn. Cremated remains
generally are pulverised well 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 tilt 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 salable 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 wig be dons in privacy,with dignity and respect.
)DENBEI_CATIQI9 QF DECEASED
Barbara D.Flynn t.Mdow
Name of Deceased: Marital Status:
6249 State Route 30,Indian Lake,NY 12842
Last Kncwm Address:..,
re$Idence
?face of Death.
86 101201193fi 4128/23 , _ �60"".a100
Gender tit 'r F X Agee DOB Date of Death: - _ Estimated Weight
Description of casketicontainer in which remains will be delivered.including manufacturer or supplier and material.
McDonald Container,basic cremation container
PERSON IN CONTROL OF DISPOSITION
(oersan(s)in wader of dfspasition,f!!ittaf ONE of the fok:wiry)
iWNW are the designated agent of the deceased designated in a wit or written instrument executed pursuant to Public
Health Law Section 4201
1fVlia have no knowledge that the deceased executed a written Instrument pursuant to t'tmpc Heahtl Law Section 4201 or
a wail containing directions for the disposition of ha or her remains and thee are the persons)having priority under Public
Health Law Section 4201 and have the right to authorize cremation of the remains of the deceased. My1Our relationship
to the deceased is as follows:
•
DOS-1898-f(Rev.01/23) Page 1 of 3
Authorization for Cremation and Disposition
;Insert Yearn the first be%w)
Number 3 _ Description:daughters
t_ 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 or age or older,
4. A surviving parent:
5, A surviving sibling eighteen years of age or cider
6.. A lawfully appointed guardian:
7. Any person(s)eighteen years of age or older entitled to share in the estate end who isiare 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;
tpa. Any other person who is acting on behalf of the deceased and who has executed a written statement pursuant to Publc Health
Law Section 4201(7),
For numbers 3.5 and 7 above,by signing,floe persons)signing this Authorization Form represent that they are signing on behalf of a
moiety of the members of this class of persons who are reasonably amiable.
BOP/of the fosowing)
Mb PMC
I/We hereby atfinn 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
�y to remove these items prior to cremation may result in harm to the crematory and crematory personnel.
"'r�IMfe affirm that instructions have been given to Patricia Miller
rfimnw sierra•sent
regarding the removal of any personal property or other g of value which any person signing below or any fateiy
member of the deceased wishes to preserve. Pine View Crematory
`fSaaiaS�,Aarv.!
is riot 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.
Oreltel OPTIONAL#
Thee 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 rirector,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
burial in Cedar River cemetery
if the funeral director whose signature appears on page three of this Authorization Form is not the person authorized to receive the
cremated rsrnaihs of the deceased from the crematory.provide contact information for that person or persons:
tf for any reason the person named above does not fake possession of the cremated remains,
flute View Crematory ._. is authorized to give possession of
Miller Funeral Home the remains to by delivery in
_�...i*snnaar Name,
in person or via delivery by the United States Postal Service,as permitted by its regufaeons and procedures_
DOS.t898-f(Rev 01/23) Page 2 of 3
Authorization for Cremation and Disposition
(10,M-Me fokomrigi
I/We understand that tithe remains sre not claimed within 120 days of crernabon.
Pine View Crematory may dispose of the remains
puma Groaxr..
an irretrlevaise manner.such AS by scattering.
CREMATION CONTAINERJURN
/initial\ONE of the following)
Pine View Ciernatory
INVe have prowl- ed with an urn to be used as a container for the cremated
riCnmature
11§111RWCS.The um is described es follows;
Pii1Reeia )
Me understand that if the urn is too=al to hold the entire cremated remains,an additional rigid container may be used
for delivery.
-OR-
I 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
a rigid temporary container for delivery.
Patricia Miter
This Authorization Form was provided by was executed at
Miller Funeral Home
Na,-t I
6357 State Route 30,Indian lake,NY 12842
)0,,tera,•T'e. Adorssok.
and is signed by the funeral director as witness to its execution:
iftNe have received a completed copy of this Authorization Form.
UWe miare the person(%)in control of disposition,who by signing this Authorization Form,attest(*)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 day of i--vwr' f
Dedre Flynn
--)t"
zoirem,
13249 Slate Route 30,Indian Lake,NY/2842
Dawn Flynn r4
'Wet(cv cvmelf Alm*
fi249 State Route 30.Indian Lake,NY 12842
Altkeers
. _
Typata PAii110 Mow Sgmtm
ArAitta ,
WITNESS:
Pa Miller
ijk_ 6111 CJ
7mea
12465
__ _