Parker, Geogianna Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: 4 I 70 113 /;?a f h
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
NAME: C'EzeG NN FAO<CP CASE # so3
TYPE OF CONTAINER: P►4MS�,U. - �rq� 1 N3 7 / Rp(6o�gpo
PLACE OF DEATH: Lj l25 poce �`p fi(—�F / Mx 17 53r
ESTIMATED WEIGHT OF REMAINS & CONTAINER I S71 L S(
PLACED IN HOLD:
PLACED IN REFRIGERATION: �'i(S J h
DATE OF CREMATION: (o Ill I Z3
TIME STARTED: II X)All TIME COMPLETED:
PLACED IN RETORT: II: fn MOVED: /l' 6sAi I �'ju��
RETORT# IN WHICH REMAINS WERE CREMATED: SSP K 41�
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.
New York State
Department of State
NEW YORK Division of DIVISION OF CEMETERIES
STATE OF One Commerce Plaza
OPPORTUNITY, Cemeteries 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.
6/12/23 SQ3
Date: Case Number(for crematory use only):
Pine View Crematory
Crematory Name:
Quaker Road, Queensbury, NY 12804 518-745-4477
Address: Phone:
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 le,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 incidenta' 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 t"e 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
Qeorgiacna Parker Never Married
Name of Deceased: Marital Status:
4"2q Fi^ckwell St., Hadley, NY 12835
Last Known Address:
residence
Place of IDeath:
l
Gender: I I M r F[1-1 X Ace:67 DOB: 9/29/55 Date of Death: 6/12/23 Estimated Weight: 150
Description of casket/container in which remains will be delivered, including manufacturer or supplier and material.
Batesville rental casket insert; cardboard
PERSON IN CONTROL OF 7,'SPOSITION
(Person(s)in control of dispos;rion, 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.
ii\-OR�
,,,///��/��' I/We have no knowledge that the deceased executed a written instrument pursuant to Public Health Law Section 4201 or
a will containirc 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
Authorization for Cremation and Disposition
(Insert from the list below)
Number: 5 Description: sister
1. A person designated i, writing pursuant to Public Health Law Section 4201(3);
2. The surviving spous.:;
2a. The surviving domestic partner;
3. Any surviving chid eigceeen years of age or older;
4. A surviving parent;
5. A surviving sibling eighteen years of age or older;
6. A lawfully appointed than;
7. Any person(s) eic.btiEen 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` '!::' of the estate;
9. A close friend or "el^±i, 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 w.�h^ acting on behalf of the deceased and who has executed a written statement pursuant to Public Health
Law Section 4201(1
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 cr class of persons who are reasonably available.
(Initial BOTH of the following)
yfriLinV 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.
Patricia Miller
I/We affirm that ihstructions have been given to
(Funeral Director Name)
regarding the removal of any personal property or other thing of value which any person signing below or any family
member o u s :: :..eased wishes to preserve. Pine View Crematory
(Crematory Name)
is not responsible to the removal of personal items from the container or from the remains of the deceased. Personal
items !eft in t":e container or with the remains will be destroyed by the cremation process and cannot be retrieved
after cremation.
(Initial OPTIONAL)
I/we hereby a <thorize the named funeral director to provide for delivery to and cremation by an alternate
crematory. +i;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 restinci plac?for'i eibated remains of the deceased is
return to family
dW66dAJ+v]gyp
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 cry.c.E*-F.,i,sed from the crematory, provide contact information for that person or persons:
Name (Address) (Phone)
If for any reason the person :lamed above does not take possession of the cremated remains,
Pine View Crematory
is authorized to give possession of
(Crematory Name)
Brewer Funeral Home, Inc.
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. 01/2 Page 2 of 3
Authorization for Cremation and Disposition
(Initial the following)
>14 I/We understand that if the remains are not claimed within 120 days of cremation,
Pine View, Crematory
may dispose of the remains in
(Name of Crematory)
an irretrievable manner, such as by scattering.
CREMATION CONTAINER/URN
(Initial ONE of the following)
Pine View Crematory
I/We have nrovirlsd 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 t-at if the urn is too small to hold the entire cremated remains, an additional rigid container may be used
for delivery.
-OR-
xP I/We have not provided an urn to be used as a container for the cremated remains, and understand that
in...,
Pine View Crematory
will place the cremated remains in
(Name of Crematory)
a rigid temporary container for delivery.
Patricia Miller
This Authorization Form was provided by was executed at
(Funeral Director Name)
Brewer Funeral Nome !-
(Funeral Home Name)
24 Church St., PO Box 90C Lake Luzerne, NY 12846
(Funeral Home Address)
and is signed by the fun ra, ci ir..aor as witness to its execution.
I/We have received a compibitsci copy of this Authorization Form.
IiWe is/are the persons; in r;ontr'ol 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.
12 June 20 23
Signed this .''.
Marcia Parker „aZ, a/le LA 1�
Typed or Printed Name `6ignaturt
8 Whitbeck Dr.Appt. 814. Cu.:ensbury, NY 12804
Address '
Cynthia Martin '
Typed or Printed NanTe Signet
61 Lake View Circle Dr _ :<<- ^eorae, NY 12845
Andress y
T-/oed or Panted Name Signature
Address ---___
WITNESS:
Patricia Miller 6}14.-epQl
(curare!Ceac ur Typed or Printed Name (Funeral Director Signa
12465
(Registration Number)
DOS-1898-f(Rev. 01/23) Page 3 of 3
Pine View Cemetery and Crematorium
21 Quaker Road
Queeiisbury, NY 12804
Auth()rl%atio11 to Separate Cremated Remains
I uncral I lone 7,--- J—E
1)ircctot - -- `-J1 Jf .-----
Daft' & Pofcq3 Tag No. ,5Q - - ---
I/w•c autl►orizc the separation oldie • • •ntaletl remains of
____aacier_Qn.laa soLf-- 1- cr
I/we further agree to hold harmless, indenuliIV and defend llte herein named crematorium as well
as their representatives, from and against all claims, liabilities or damages «•Itatsocvcr which may
result from this auth Wir.ation.
Signature - _
Crematory Operator -_
March 2015