Duffy, John P •
Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: LG� E
RETURN TIME:
ctzit
DATE 8 TIME REMAINS ARRIVED AT CREMATORY: 11/1'Ll 15
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
Tbn2L'�{ M
NAME: PJGF�
CASE # 3� —
TYPE OF CONTAINER: t iOvroOC>v l•risc - /412o5D
- z�E
PLACE OF DEATH: 121 PIuD.s,J 511Z&t ' So"t k4.4.1r f'K- tigu3
ESTIMATED WEIGHT OF REMAINS 8 CONTAINER I 6b r I 114 IL 5q/./
PLACED IN HOLD: I0 3, 411
PLACED IN REFRIGERATION:
DATE OF CREMATION: `/j 13123
TIME STARTED: ) 20 iffll TIME COMPLETED: /D:351'11
PLACED IN RETORT: 7:ToiPoi MOVED: g- s (1-11.16'itn
RETORT# IN WHICH REMAINS WERE CREMATED: T Pett 10'1)Q1171
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). New York State
f Department of State
•
DIVISION OF CEMETERIES
Of
, '. 11 one Commerce Plaza
IS�C
99 Washington Avenue- Y:
w t1 meteries Albany,NY 12231-0001
�` � r r �r Telephone:(518)474G22G
,r
M www.dos ny.gov
a • fellation and Disposition
�� �� '��olii�litfitail Porrn must be completed and signed prior to delivery of remains for cremation.
• 33W
Gase Number(for crematory use only):
xatant
.-QUegasgury,NY 12804 Phone: 5184454477
A N : ►L PROCESS.
rer 3ifit ofthedeceased and the container holding the remains into a cremation chamber where
halt'snotflame. The heat and flame will incinerate and consume everything except bone and metal,
•
laigieleasonable efforts to remove all of the remains and other material from the cremation
likely be'lett behind. The crematory will separate incidental and foreign material from
rrlaten•al,including dental work and implants,will be disposed of as permitted by law. The
into small pieces and placed into a designated container or urn. Cremated remains
nt is recognizable as skeletal tissue.
. the un-cremated human remains in limited circumstances, such as to confirm the
`'� r is enclosed which might injure employees or damage the crematory property. If
no#suitabie for cremation such as ceremonial or rental casket,the,
ed into a suitable container before it accepts the remains. The opening of a
:'
• s � + be conducted before a witness and will be done in privacy,with dignity and respect.
box
S
• ` .'
Marital status:
Divorced
R e Glens Falls,NY 12803
• � t Falls,NY 12803`
� *� _ � t altta trf Death,04-07-2023 Estimated Weight: 150
z '=manufacturer or supplier and material
3,y �
=y �� Wrtt �M�eftt tiottict�pfttto Pubtic
P
tvi 4 4*
rx u�3.
•
, a ;
��K
for Cremation and Disposition
L)esCxrption Any surviving child eighteen years of age or older
in writing pursuant to Public Health Law Section 4201(3),
• x >, domestic partner;
k ��° Ehild;eighteen years of age or older;
ment
eighteen years of age or older;
tad guardian,
�"
�iteen Years of age or older entitled to share in the estate and who is/are closest in relationship to the deceased,
:4 anted fiduciary of the estate;
4 _ gi nd or relative who has executed a written statement pursuant to Public Health Law Section 4201(7),
lei officer of a'count y.Or a public administrator appointed pursuant to the Surrogates Court Procedure Act.
person who is acting on behalf of the deceased and who has executed a written statement pursuant to Public Health
3. and 7 above,by signing,the person(s)signing this Authorization Form represent that they are signing on behalf of a
of this class of persons who are reasonably available.
`%° rirti-that the body of the deceased does not contain a battery,battery pack,power cell. radioactive implant.
radioactive device and that any such materials were removed prior to the execution of this Authorization Form. Failure
;items prior to cremation may result in harm to the cremator Lan crematory personnel
I(9j_ C . A.1 1ine-r
have been given to
(Funeral Director Name)
R -,l ofatsy personal property or other ' of val w n hich any p signin below or any family
ad'��topreserve. 4 V 11441 � �
4. (Crematory Name)
•
iremoval of personal items from the container or from the remains of the ceased. Personal
lihtit er or with the remains will be destroyed by the cremation process and cannot be retrieved
�, le named.funeral director to provide for delivery to and cremation by an alternate
In the`opinion'of the funeral director,and to amend this form to provide the
such alternate crematory.
•
r ins of the deceased is
F
x e 6` to Form is not the person Oitioti KKeeppr receive the• `
•
e#
a w �n-�4hat persoh>or persons.•
x ��.?r.'arc• �`'��" ,� ��t'.. ,.�� �`S��' ; y-��'�•y'y ram,�t '.
y p.b 4 k "�'F ted remains,
•
t' 444400wed to„ the p Pssiof F•
of .
•
r
1
d�t ice 1,, .. T->=_ ., '� � � _ .x'� ..- -,.sosn,x�-w..P..—�.�•,..,a_ . h
Y
�{a Of and DispositlO _ ys�
rs- .HS+ ._ � •
r,,, ,.� ,"'- ,. Rom.»� .. @x '
. a X �i iher reMiliins ere not claimed within IV t lya-of cremation,
5 • -, may dispose of the remains in .,. 10
�-- ,. fNMtie ti Creinarcryl -
r manner such as by scattering.
?" -X t`. � with an urn to be used as a container for the cremated
� x ,0 b - dinegc,..0Y). I
r > �t t o foitows
S�F
I i H J `':Y
,' ,'. if 4,m is tao small to hold the entire cremated remains,an additional rigid container may be used
' f ` s � � � ��;;*labe used as acontamer ion,the.cremated remains,ancJ understand that
�" � � •
place the cremated remains in
f at#�r!!naaor will
was executed at
a pnsr iD,8 or Name) i
4
ra
' '.• •"•••'''''"'-''''''";`;'<:1,,,---Alfw,7,'.::-,:g ---'±.:".".', ",-•-•.,.'r-S'''''''',''''''''',:'''''''•'':' •,••..,'....),•
F at.fsexecijton. _
*tq. Y'ri'ti, -_
"Y is,#ti #torization,Fgrm,attests)to-the accuracy.and ,
`#sa s nd hereby authorizes)to cremate the:'remains of the
1 i 3 "WtWAVW ib d
as -n,t �:.; '� :Z. �R, 1 ',4 1 .'y .t 1 h ,-Z ',11i.: hr
' .
ivy '.." 6.',,'" p"w y *' '..1 Y. 4
,�- '. & s D fi '5Pa" ' � r � 74
,4 F psi
mot > a : ° . ? 4.01 t
v
+ ti t ry x .. w"a
° -xA
r
t,
r