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Gibbs, Judie LF Pine View Cemetery & Crematorium Quaker Road Queensbury, NY 12804 (518) 745-4477 or (518) 745-4476 FUNERAL HOME: ki MCfl RETURN TIME: DATE 8 TIME REMAINS ARRIVED AT CREMATORY: 31)4 2 Aireh NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS: T0op NAME: QUDLE 1336' CASE # Z 5 g TYPE OF CONTAINER: -CnaEuPE lea" 4. / tgappoi4 � ref frtZ- PLACE OF DEATH: /Old zI SSE jdvrE Lit µj t7132 ESTIMATED WEIGHT OF REMAINS 8 CONTAINER /00 At- / yolyo. Se PLACED IN HOLD: 24-5' fti PLACED IN REFRIGERATION: DATE OF CREMATION: 3[31 23 TIME STARTED: /1 Do TIME COMPLETED: f 2 To Pt) PLACED IN RETORT: ilia\ MOVED: /I y / /) li h i Ij ton) RETORT# IN WHICH REMAINS WERE CREMATED: i oN,J62 P1 k 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. r A New York State rri Department of State NEW PORK Division of 411iDISION OF CEMETERIES STATE OF One Commerce Plaza OPPORTUNITY. [C m # 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. m . 3/25/2023 2 Date: Case Number(for crematory use only): ation D Crematory Name;Pine View Crematory Address:21 Quaker Road, Queensbury, NY 12804 Phone: 518-745-4477 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 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 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 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:Judie Gibbs Marital Status; Divorced Last Known Address:Slate Valley Center, 10421 State Route 40,Granville NY 12832 Place of Death: Slate Valley Center, 10421 State Route 40, Granville NY 12832 Gender: El M El F El x Age'77 DOB'09-25-1945 Date of Death:03-23-2023 Estimated Weight- 100 Description of casket/container in which remains will be delivered,including manufacturer or supplier and material. Minumum Cremation Casket, Florence Casket Co. Cardboard/Pine PERSON IN CONTROL OF Dl8POSITloN (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 He Law Section 4201. -OR- c I/We 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: L1 - Cir` DOS-1898-f(Rev.01/23) Page 1 of 3 Authorization for Cremation and Disposition (Insert from the list below) Description: A survivng sibling child eighteen years of age or older Number 5 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. (!nit) I BOTH of the following) .1*.,...: _f._ 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 to remove these items prior to cremation may result in harm to the crematory and crematory personnel. _ I/We affirm that instructions have been given to n }C)c a n )1 L ,- (Funeral Director Nome) regarding the removal of any personal property or other t( g of value' hich any perso`signing below or any family J �1 member of the deceased wishes to preserve. r e V 1 e L,{ e_ -1'A(.;� •( (Crematory Name) 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) Uwe 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 Give to Nancy If the funeral director whose signature appears on page three of this Authorization Form is not t e person authorized to receive the cremate mains of th a d fr m the crematory, provid ontact info tion for th on or pe sons. _ (Name) / t--- (Adores � � � � one) 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 Nome) M.B. Kilmer Funeral Home the remains to 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 I a Authorization for Cremation and Disposition ln'' wing) INVe understand that if the remains are not Gamed within 120 days of cremation, Pine View Crematory may dispose of the remains in (Name W crematory) an irretrievable manner,such as by scattering. CREMATION CONTAINER/URN (Initial OBE of the following) I/We have provided ?Lr k.) with an urn to be used as a container for the cremated (Name of crematory) 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- I/We have not provided an urn to be used as a container for the cremated remains,and understand that Pine View Crematory will piece the cremated remains in (Name et Crematory) a rigid temporary container for delivery. This Authorization Form was provided by Morgan Wicks was executed at (Funeral Director Name) M.B. Kilmer Funeral Home (Funeral Hone Name) 82 Broadway, Fort Edward,NY 12828 (Funeral Hare Address) and is signed by the funeral director as witness to its execution. INVe 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 authorizes)to cremate the remains of the deceased. S , igned this 25th day of March 20 23 Nancy Fishelson /1,1d/ Typed or Petaled Name 142 Hazel Plain Road,Woodbury CT 06798 Addeas Typed or Printed Name signature Address Typed or Printed Name Signature Aar WITNESS: Morgan Wicks (Funeral Director Typed or Printed Name) (F 14694 U T pia is moo/neon Number? usr DOS-1898-f(Rev.01/23) Page 3 of 3 M.B.Kilmer Funeral Home Customer's Designation of Intentions Name of Deceased:Judie Gibbs Date of death;March 23,2023 Crematory:Pine View Crematory,Queensbury NY Scheduled date:March 27,2023 Manner of Disposition of Cremains: Q Burial 0 Entombment El Scattering: At(location): 10 Given to(name):Nancy Fishelson 0 Other(describe): Acknowledgement of Manner of Disposition Selected 1,Nancy Fishelson,designated the manner of.disposition as described above. Address: 142 Hazel Plain Road,Woodbury CT 06798 Phon #:310-508-1446 Date:03/25/2023 Signature: Disposition of Unclaimed Cremations 1.Cremains which shall not have been claimed within 120 days from the da of cremation may be disposed of by this firm in the following manner of disposition:Burial. 2,A copy of this designation has been provided to the customer. Funeral Director:Morgan T.Wicks Da •03/25/2023- Funeral Director Signature: 44441 THIS SECTION TO BE COMPLETED FOLLOWING CREMATION 4144 Cremation Took Place Crematory:Pine View Crematory,Queensbury,NY 12804 Date: Date and Manner of Disposition Disposition Date:---- Disposition Manner: 0 Burial 0 Entombment L7 Scattering: At(location): ©Given to(name): 0 Other(describe); Funeral Director: Signature: —__ Date: Dote: When the manner of disposition is"given to" or`other,"the person receiving and taking possession of the cremains for final disposition must complete and sign this section: ,have received and taken possession of the cremains described above for final disposition. Signature: Date: