Mackrodt, William A LF
Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: d p t 5 RETURN TIME: NOmE
DATE & TIME REMAINS ARRIVED AT CREMATORY: 31311 2,3 /D;oo
otti
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
'EaD'1 (3u cLC .1
NAME: N Wit( An A. owe?l - CASE # Z11
TYPE OF CONTAINER: DvFp-Ato IA5a4-- MPA M1
Aq N►RT.Wt fowCp rr'
PLACE OF DEATH: 5A2sT66-4 I-16-, ,q L
ESTIMATED WEIGHT OF REMAINS & CONTAINER I iI
PLACED IN HOLD: O. lb
Arl
PLACED IN REFRIGERATION:
DATE OF CREMATION: 3131 I Z3
TIME STARTED: [1 C f'n TIME COMPLETED:
PLACED IN RETORT: / Pn MOVED: Z op t Z .L0 pp
RETORT# IN WHICH REMAINS WERE CREMATED: fwr� fAl(i�
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.
Docc ign Envelope ID:2E5CF949-00D3-438C-8288-8BAAA5DA2DC6
New York State
fl—INEW YORK Division of Department of State
STATE OF
DIVISION OF CEMETERIES
OPPORTUNITY. Cemeteries One Commerce Plaza
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: 03/30/2023 Case Number(for crematory use only): 2 11
Crematory Name: Pine View Crematory
Address:Quaker Road, Queensbury, NY 12804 Phone: (518) 745-4476
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 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: William A Mackrodt Marital Status: Married
Last Known Address:314 Loudon Road, Lot 86,Wilton, NY 12866
Place of Death:Saratoga Hospital, Church Street, Saratoga Springs, NY 12866
Gender: ®M ❑F ❑X Age: 81 DOB: 12/19/1941 Date of Death: 03/28/2023 Estimated Weight:
Description of casket/container in which remains will be delivered,including manufacturer or supplier and material.
Buffalo Casket Company—Alt Container
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-ros
/ /Q/�
'/ IIWo 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
DoouSign Envelope ID:2E5CF949 000D3-438C-8288-8BAAA5DA2DC6
. . ... ..��••��� ��. scsi�aucil►1 ana UISpOSlt,ofl
(Insert from the list below)
Number: 2 Description:Spouse
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.
(In 4 ��I of the following)
I/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
07,
remove these items prior to cremation may result in harm to the crematory and crematory personnel.
A
I/We affirm that instructions have
a e been given to Mark J. DeSimone
(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. Pine View Crematory
is not responsible for the removal ofner(Crematory Name)
ns of the deceased. Personal
items left in the container or with the remains will be destroyed by the remation or from the 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
Return to Liza Bizon— Daughter
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:
Mary Ann Mackrodt 4123 Dartmoor Court, Fredericksburg, VA 22408 (518)932-8163
(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 Regan Denny Stafford 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
Doc`tSign Envelope ID:2E5CF949-00D3-438C-8288-5BAAA5DA2DC6
Authorization for Cremation and Disposition
7gliowing)
I/We understand that if the remains are not claimed within 120 days of cremation,
Pine View Crematory
(Name ofCrematory) may dispose of the remains in
an irretrievable manner, such as by scattering.
CREMATION CONTAINER/URN
(Initial ONE of the following)
I/We have provided Regan Denny Stafford Funeral Home with an urn to be used as a container for the cremated
(Name
remains.The urn is described as followsdlcren,atoy)
I/We understand that if the urn is too small to hold the entire cremated remains,an additional rigid container may be used
R �� r delivery.
le have not provided an urn to be used as a container for the cremated remains,and understand that
Pine View Crematory
(Name or Crematory) will place the cremated remains in
a rigid temporary container for delivery.
This Authorization Form was provided by Mark J. DeSimone
(Funeral Director Name) was executed at
Regan Denny Stafford Funeral Home
53 Quaker Road,neral Queensbury, NY 12804
(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,attests)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 30th day of March ,20 23
Mary Ann Mackrodt
Typed or Printed Name Signature
4123 Dartmoor Court, Fredericksburg, VA 22408-
Address
ref
Typed or Printed Name —.
Signature EEF7C1732538428_.
Address
Typed or Printed Name -
Signature
Address
WITNESS:
Mark J. DeSimone
(Funeral Director Typed or Printed Name)
(Funeral Director Signet )
10919
(Registration Number) ..
DOS-1898-f(Rev. 01/23)
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