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O'Neil, Larry Gordon Pine View Cemetery & Crematorium Quaker Road Queensbury, NY 12804 (518) 745-4477 or (518) 745-4476 FUNERAL HOME: MRj r iU7 RETURN TIME: Al DATE & TIME REMAINS ARRIVED AT CREMATORY: q' / 3 1 l3 2,e v et1 NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS: NAME: &AP124 0'u4. CASE It 3°3- TYPE OF CONTAINER: e CA5t0-(O_ .Tov6 PLACE OF DEATH: 110 '-" Re(R e6bs j2r (tigoj ESTIMATED WEIGHT OF REMAINS & CONTAINER /To I(,c PLACED IN HOLD: 2 , c-0) PLACED IN REFRIGERATION: DATE OF CREMATION: Inv TIME STARTED: -1 5-1 Pril TIME COMPLETED: 1'0 3U/41 PLACED IN RETORT: Lu MOVED: 9 ob I.zv "i"iJ o RETORT# IN WHICH REMAINS WERE CREMATED: 5't,i;4.1t Power e4i 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. 1 RECEIVED 04/03/2023 10:54AW Apr 02 2023 02:54PM Kirner FH 15187451987 page 1 New York State EWVoRK Division of 4N.. DoPertment or u DIVISION OP CEMETERIES One Commerce Raze Cemeteries 99 Washington Avenue Albany,NY 12231-0001 Telophonep(51514744224 • www.doany.gov Authorization for Cremation and Disposition Thla Aufhortxetoe Form must be completed end signed prior to delivery of remains for promotion. Dam March 27 2023 Case Number(for crematory use only): 3os Crematory mimic Pine View Crematory Address:21 Quaker Road Queensbury,New York 12804 Phone: 51&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 llama. The heat and flame will Incinerate and consume everything except bons 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 end other material from the cremation chamber,but comp minimal dust and residua will likely be left behind. The crematory will Separate incidental and foreign materiel 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 email pieces and placed into a designated container or urn. Cremated remains generally are pulverized unto no single fragment la recognizable as skelal tissue. • +genliMF T1tE OONTAINER The crematory stay only open the container holding The un-cremabd 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 COMainer whist'is not suitebis forcremation such as ceremonial or rental casket,the crematory will require that the remains be moved Into a suitable container before Nampa'the remains. The opening of a container or she ranter or removal or remains will be conducted before a witness and will be done In privacy,with dignity end respect. IDENTIFICATION OF DECEASED Name of Deceased:Larry Gordon O'Neil Martial Statue;Single Last Itnewn Address:1890 Route 9 South Glens Falls,New York tiA4—; Place or Death.The Pines 170 Warren St.Glens Falls,New York FIg3 Gender. I]M©F 10 X Age:79 DOB.04 10-1943 pate of Death:03-27 2023 Estimated Weight 150 Description of casketioontainer In which remains will be delivered,including manufacturer or supplier and material. Minumurn Cremation Casket,Florence Casket Company Cardboard/Pine emu N CONTROL OF Di8PO81TIOr( i (Person(S)M Oo ltrof aaiaposmon,oft ONE of me wowing) I arnlwg are the designated agent or Ins oacaseaa desgneoan in a mil or written Instrument executed pursuant to Public Health Law Section 4201. • -OR- pt to INVe have no knowledge that the deceased executed a written Instrument purevent to Public Health Law Section 4201 or a will containing directions for the disposition of his or her remains and Uwe are the personto)having priority under Public Heath Law Section 4201 and have the right to authorize cremation of the remains of the deceased. MyiiOtir relationship to the deceased Is as follows: DOS-18910(Rev.01123) Page 1 of 3 RECEIVED 04/03/2023 10:54AM Apr 03 2023 02:54Pt1 Kirner FH 15187451987 page 2 Authorization for Cremation and Disposition (Insert from the Nat below) Number.7 Description:MY Person eighteen years of age or older entitled to share In the estate,lane closest in relation 1. A person deslonated in venting pursuentto Public Health Law Section A201(3); 2. The surviving spouse; 21. The surviving domestic partner, • 3. Any surviving child eighteen years of age or older; 4 A surviving parent; B. A surviving soling eighteen years of age or older. 8. A lawfully appointed guardian; 7. Any person(s)eighteen years of age or older entitled to share in the estate and who is/are olosaet in relationship to th.deceased; a. A duly sppomtod fiduciary of the estate; It. A class Mend or relative who NS executed a written statement pursuant to Public Health Law Section 4201(7); 10. A chief fatal ofAcer of a county or a public administrator appointed pursuant to the Surrogates Court Procedure Act; lea. Any other person who Is acting on behalf of the deceased and who roe executed a written statement pursuant to Public Health Lew Section 4201(7). • For numbers 3,6 end 7 oboes,by signing,the person(s)signing this Authorization Form represent that they ere signing on behalf of a mWoltty of the members of this claw of persons who are r asonably available, (Mg_BOTH of the following) • ftb�`' IMIe hereby OM that the body of the deceased does not contain a battery,battery pack,power cell,radioactive implant, or radioactive device and that any such materiels were removed priorlo the execution of this Authorisation Form. Failure �,// to remove these Items prier to orematlon may result in harm to the crematory and crematory personnel. "' 'IVY@ affirm that Inalfuctions have heart given to r"' �' r m.W .erori*nel regarding the removal of any personal properly or other thing of velure which any parson*Coning below or any family member of the deceased wishes to praaerve. 'e (Owre yAl�mr) is not reaponabia for the removal of personal hems from the container or from the remains of the deceased. Persons' • Items left In the container or with the remains will be destroyed by the cremation process end cannot be retrieved after cremation. jiog(aLOPTIONAL) 11we hereby motherfso the named funerei director to provide for delivery to and cremation by an alternate crematory,If deemed necessary In the opinion of the funeral director,end to amend this form to provide the correct name and eddrea of such alternate crematory. FINAL DISPOSITION The final resting place for the cremated remains of the deceased Is Burial Elouttalde Cemetery If the funeral direotOr Wbae algnature appears on Page three of this Authorization Form Is not the person authorized to receive the cremated remain of the deceased from the crematory,provide contact information for that person or persons; • ram* (Addian) mans) 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 ( NW* the remains to M t3 Kilmer Funeral Homo by delivery in AN N v+aMNNW r uleiione and pr000drxas. In person Or via delivery by the United Steles Postal Service,as permitted by its roe Page 2 of 3 DOS1908-f(Rev.01/23) RECEIVED 04/03/2023 10:54AM Apr 03 2023 02:54PM Kliier FF 15187451987 page 3 Authorization for Cremation and Disposition a2161 rho ibGkowmg) • P INVe understand that l the remains are not claimed within 120 days of cremation, Pine View Crematory may dispose of the remains In ilVCnmrmr) an irretrievable manner,such Ma by scattering. CREMATION CONTAINSRAIRN pnprei ONI of GAS fOlOwing we haws provided Pine View Crematory velar an um to be used as a container for Si.cremated (Nand Canon remains.The um le deacnbed ea fciloww _Me understand that If the urn is too email to hdd the entire cremated remains,an additional rigid container may be used for delivery. -OR- et"t° life have not provided an urn to be used as a oontalnerfor the cremated remains,end understand that Pins View Crematory will place the cremated remains In (Nmnodu rnabol a rigid temporary container for delivery. ThIs Authorization form was provided by Claire C.Karwpka -._ was executed at rr+nI,W Arent r NM$ M B Kilmer Funeral Home Amore Atom Nino) 136 Main St.South Glens Falls,New York 12803 MinwONanIAona) end Is signed by the funeral director as wltrwss to its execution. 1/We have received a completed copy Of this Authorization Fenn. lade Warier the pwsonis)In control of dlepoottlon,who by signing this Authoriza ion Form,attend.) tolab the r the emains ns of the itry and completeness of the Information;ontained in this Authorization Form and hereby authortss(s)to densesd. - -- -- eland this 3 day at 'h .(0 3 ` Brandy L O'Neil � j ��..�t � Voter �e 655 Etta*Hill Road Gienalds PA 19038 Atlmen Typo or Printed Nam *Vlore /C M ry0dpkmWMmo fir° . Adawrs MNTNEOS: Claire C.Konopks runlet GnawmegorfenlodNwry) fir"°W') 11932 2109Bgrann4 Page 3 of 3 DOS-1895-f(Rev.01t23)