Lindsey, Gerald F LF
Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: /y/,'
/ RETURN TIME:
DATE 8 TIME REMAINS ARRIVED AT CREMATORY: 9—`O
� y z z4,z 3
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAIN
NAME: t4. �
/ CASE # 3�
TYPE OF CONTAINER: C c %� S ` • (
PLACE OF DEATH: v.J eJ;
ESTIMATED WEIGHT OF REMAINS 8 CONTAINER / .3-/X 7 �
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION: �/-Z Z-ZrZ 3
TIME STARTED: /() _ TIME COMPLETED: 12 "
PLACED IN RETORT: 6�/�'�
`/ i Z i
RETORT# IN WHICH REMAINS WERE CREMATED: 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.
Naw A.state
Department of State
NEW PORK Division of DIVISION OF CEMETERIES
STATE OF a a
OPPORTUNITY Cemeteries
Authorization for Cremation and Disposition
This Authorization Form must be completed and signed prior to delivery of remains for cremation.
4 20,23 '4 .
Case N ,be ;^ atop _a cr,r'
• Date. r rr - ---------Pine View Crematory
Crematory Name.
13-745-447
Quaker Rd.- Queensdury �v y 12811,1 o�...,
Address:
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS
Cremation Is carried out by plac'no the remains of the oeceased Cr d the contaiier hoioing toe temans into a cremation chamber where'.
they are subjected to intense heat and fame. The heat and flame will incinerate and consume everything except bone and metal.
which are all that will be left after cremation.
Following cremation. tie crematory w li take re.asnnaole efforts to remove all of toe remains and other materal frorn the cremat.Or
cnamber. but some minima dust and residue will i,Keiy ne ie"t behind Tie crematory separate incidental and foreign material from
tie remains and the incidental anc foreign matera:- inc,,:ling dental work ern ants v i 'Oe disposes of as permitted by law The
cremated remains will be mecharncall, ojiverzed nto small pieces and placed into a ces anatea container or urn Cremated remains
generally are pulverized until no single fragment is recognizable as skeletal tissue
OPENING OF THE CONTAINER
The crematory nay only open the'cat railer no d ng toe -:re I ed r.Jman <" mn; ,s i iimirec circumstances such as to confirm the
Identity of the ceceased or to ensure mar no material is enclosed .wrch might iniore emal -yees 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 Va ��=
nsfer o'ran r of re_na ids Ce dnc_ec oefore a 'c otnesa_or: will be_tont-irl nnvarcy with dignity and respect.
- -
IDENTIFICATION OF DECEASED
Gerald F _Ind,e, Married
Name of Deceased 1artai Status
20 Stever Dr R;-cc;hamton NY 'i9L
Last Known add,ess
Wilson Med cal Cer" e Johnsor '� ' N` iiocv
Place of Deato
i 25 3 4 'a '3— — Est;r ,ated Weight. , D.
x i X ge DC,I� Date of
Gender M F — —
Description of casket.container yr i,.l 'ems .c NJ'll _ berco "lr:' JO. _:a. „,er anc materiall,
McDonald Basic Cremation Ccn'.ainer
PERSON IN CONTROL OF DISPOSITION
,Person(s) dispos t on e ONE of ram..
t c cesi :7teco Or ,,rittfrf st-1st execote� Di,.ur5,.art to Pubic.--
am✓r�1�e are the _te=.r;nater" � ,o r`,� ::e ::a a r � .
Health Law Sect o.n
i�.�le "a r' nor_ Kr e,�E :hat the d6Cea5-
-OR-
exe 1 en a en ; r's. rde p.i`Sua r '�to Public Health Law Section 4201 or
-rlt(ti e
a will containino directions for the disDos t 0. of his or ner remains a . e are Inc persons,having pr:anti order Public
Healtt Law Sc t,cn 42011 arcrave the r ar. to author ze. cremat o toe remains - :he accessed. My/Our relationship
to the deceased is as follows
DOS-1898-`(Rev.01"23 o
Authorization for Cremation and Disposition
(Insert from the list below)
Number: 2 Description: wife 1. A person designated in writing pursuant to Public Health Lev, 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 Israre 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 i 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)
<../14, Nile 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.
t){ } INve affirm that instructions nave been given to Patricia Miller
Name
regarding the removal of any personal property or other thing of value which any person signing below or any family
Pine View Crematory
member of the deceased wishes to preserve.
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)
.� Ilwe 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 deceasec is
burial in Long Lake Cemetery
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.
•
If for any reason the person named above does not take possession of the cremated remains.
411NE ft E4J is authorized to give possession of
the remains to by delivery in
Mtn 6��,_--____------------ — -----_
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)
IIWe understand that if the remains are not claimed within 120 says of cremation.
Pine View Crematory may dispose of the remains in
an irretrievable manner. such as by scattering.
CREMATION CONTAINER/URN
(initial ONE of the following)
Pine View Crematory• INVe have provided with an urn to be used as a container for the cremated
w
remains. The urn is described as follows:
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-
11We have not provided an urn to be used as a container for the cremated remains,and understand that
PZ 1,6 v'y(A,) will place the cremated remains in
a rigid temporary container for delivery.
Patricia Miller
This Authorization Form was provided by was executed at
Miller Funeral Home
_,ra a Ner
6357 State Rte. 30, Indian Lake, NY 12842
Hcr:e.:ooress
and is signed by the funeral director as witness to its execution.
IiWe 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 20 23 •
day of April 20
Sheila Lindsey yL /,Jl e
T✓pec •,nrea Na^:e SgnaLre
20 Stever Dr., Binghamton. NY 13901
�::fires s
Typed
Arldress
rteS-I Nar'e
~^dress
t
WITNESS:
Patricia Miller (+
rFiice a G re�!o Tyree,s•PI a v>._ F.ne,.al 1ei.r S^^o��� 3
12465
,Reggio•anon Dew
DOS-1898-f(Rev. 01/23) Page 3 of 3