Dane, Susan •
Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: t1 p. RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: -)I 'n 1 Z3 f0;30
pirl
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
NAME: --- _ *pp) PAO E CASE # 02
TYPE OF CONTAINER: FCd2ELce AsIGa—co. GA rap s
PLACE OF DEATH: 14.Or F4C 1- HisPi-iPt
ESTIMATED WEIGHT OF REMAINS & CONTAINER I TO I Nd` / l64P5 {
PLACED IN HOLD: /
PLACED IN REFRIGERATION: Pi
Ail
DATE OF CREMATION:-+y 7 Z{I-Zc Z 3
TIME STARTED: 7 TIME COMPLETED: 1O-
PLACED IN RETORT: 80 MOVED: gft
I I IO
RETORT # IN WHICH REMAINS WERE CREMATED: P7 e- pe
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
ri--INEWYORK 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 ee car.pietud and signed prior to delivery of remains for cremation.
Date:July 25, 2023 CYsE Number(icr crematory use only): (00Z
Crematory Name: Pine View Crematory
Address: 21 Quaker Road Queensbury, New York 12803 Phone: 518-745-4477
CREMATION IS AN IRREVERSIBLE AND FINAL R,t:'CESS,
Cremation is carried out by placing the rer-ai i ci t'e cc' tainsr holding the remains into a cremation chamber where
they are subjected to intense heat and flame. The heat arid fla me will incinerate and consume everything except bone and metal,
which are all that will be left after cremation.
Following cremation,the crematory will take reasoneebin effort, to remove all of the remains and other material from the cremation
chamber, but some minimal dust and residue wi l likely')f left t;ehirc The crematory will separate incidental and foreign material from
the remains and the incidental and foreign material, nciuding dental work and implants,will be disposed of as permitted by law. The
cremated remains will be mechanically pulverized irr a small pieces end placed into a designated container or urn. Cremated remains
generally are pulverized until no single fragrr e:.t is .ecol;nu°able. as skeletal tissue.
OPENING OF THE CONTAINER
The crematory may only open the container holding he c:'-cre T.atec human remains in limited circumstances, such as to confirm the
identity of the deceased or to ensure that no ma:ea is enc'osuri wo ch might injure employees or damage the crematory property. If
human remains are delivered in a container which ir not Su'tabin for cremation such as ceremonial or rental casket,the
crematory will require that the remains be mover in;o a suitable container before it accepts the remains. The opening of a
container or the transfer or removal of remains will b c ir:ductea bef:ne a witness and will be done in privacy,with dignity and respect.
IDENTIFICATION OF DECEASED
Name of Deceased: Susan Dane Marital Status: Married
Last Known Address: 23 Grand Blvd South GLens Falls, New York 12803
Place of Death: Glens Falls Hospital 100 Park St. Glens Falls, New York 12801
f�1
Gender: f 1 M n F(fl X Age:59 DOB:C5.15-'',.054 date of Death 07-25-2023 Estimated Weight: 150
Description of casket/container in which remains w it be delivered. i- :iuding manufacturer or supplier and material.
Minumum Cremation Casket, Florence Caske'i Company, Cardboard/Pine
PERSON IN CONTROL OF DISPOSITION
(Person(s)in control of disposition, initial ONE of tie fc;c-,dri )
I am/We are the designated agent cf the d ,cease:: de ::,noted in a will or written instrument executed pursuant to Public
Health Law Section 4201.
-OR-
l��l!/ I/We have no knowledge that the decea.a..'.!a executed written instrument pursuant to Public Health Law Section 4201 or
a will containing directions for the disgc si':a c cif it or r remains and I/we are the person(s)having priority under Public
Health Law Section 4201 and have t-e rig it to au:nor:id cremation of the remains of the deceased. My/Our relationship
to the deceased is as follows:
•• ...:• 1. c3---,- 4..
DOS-1898-f(Rev. 01/23) Page 1 of 3
Authorization for Cremation are ti Disposib,on
�
(Initial the following)
Ick0 I/We understand that if the remains am r of ;l finer Yvr;:hir 120 days of cremation,
Pine View Crematory may dispose of the remains in
of re-ea or;.,
an irretrievable manner,such as b/sc;=tte'
CREMATION CONTAINER/URN
(Initial ONE of the following)
I/We have provided Pine View Crema or:, with an urn to be used as a container for the cremated
N,i n, of. f a ory7
remains. The urn is described as follo4:t
I/We understand that if the urn is ` _r:a n 1,.)I(i t cremated remains, an additional rigid container may be used
for delivery.
-OR-
I/We have not provided an urn to be it3e.1 as-t c;on:<,irer fcr the cremated remains, and understand that
Pine View Crematory will place the cremated remains in
(Name of r'or„
a rigid temporary container for deliverr
This Authorization Form was provided by Claire +: K)nopka was executed at
t uneral Director Name)
M B Kilmer Funeral Home
wle'3 i rr-r1(l.fi:10
136 Main St South Glens Falls, New York 12(l(3
and is signed by the funeral director as witness lc s e;:.•.:.tiio i
I/We have received a completed copy of this Author'za;icm Ftr:rr.
I/We is/are the person(s)in control of dispositic ri,w n by r c this Authorization Form,attest(s)to the accuracy and
completeness of the information contained in Ilii; it w.h,ar's:lriicr Form and hereby authorize(s)to cremate the remains of the
deceased.
Signed this 25 day of July 23_—_
Michael Dane
Typed or Printed Name ---------- ----._---- -�'�'`itu.a
23 Grand Blvd South Glens Falls, New York ";8C3
Address
Typed or Printed Name fore
Address
Typed or Printed Name .zn eture
Address
WITNESS:
Claire C Konopka
(Funeral Director Typed or Prnted Name) f`t-ierai Director Signature)
11932
(Registration Number)
DOS-1898-f(Rev. 01/23) Page 3 of 3
Authorization for Cremation aril Disposition
(Insert from the list below)
2 The surviving spouse
Number: Description:
1. A person designated in writing pursuant to i- i is::iIi:( _ayt Section 4201(3);
2. The surviving spouse;
2a. The surviving domestic partner;
3. Any surviving child eighteen years of age or c de ;
4. A surviving parent;
5. A surviving sibling eighteen years of age or el lei
6. A lawfully appointed guardian;
7. Any person(s)eighteen years of age or oide; ?ni tied to::>`ar:re 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 Nn ten staomert pursuant to Public Health Law Section 4201(7);
10. A chief fiscal officer of a county or a publi.:ad ni..isirator apon n:.ed pursuant to the Surrogate's Court Procedure Act;
10a. Any other person who is acting on behalf of tt e teaeased arc nn,ho has executed a written statement pursuant to Public Health
Law Section 4201(7).
For numbers 3, 5 and 7 above, by signing, the part c n(r:1:ncrtl a-his i...thorization Form represent that they are signing on behalf of a
majority of the members of this class of persons wtic a biy iailable.
(Initial BOTH of the following)
I/We hereby affirm that the body of the ie e 3s;c i F< ct contain a battery, battery pack, power cell, radioactive implant,
or radioactive device and that any suci' iia•€..iC s ware ro: loved prior to the execution of this Authorization Form. Failure
to remove these items prior to creme ice may r su t rr harm to the crematory and crematory personnel.
___ f _D/We affirm that instructions have Dee: c iv r tc
—� (Funeral Director Name)
regarding the removal of any persona p or other•h ng of value which any person signing below or any family
member of the deceased wishes to ores er.
(Crematory Name)
is not responsible for the removal of per;o a star, o (he container or from the remains of the deceased. Personal
items left in the container or wit:,th t re I..:r s v. t o destroyed by the cremation process and cannot be retrieved
after cremation.
(Initial OPTIONAL)
I/we hereby authorize the named tune-ar d.reo ca .n provide for delivery to and cremation by an alternate
crematory, if deemed necessary in tli 3 a oimolt r.i tli luneral director,and to amend this form to provide the
correct name and address of suo a.tier: e r, errs aic r,.
FINAL DISPOSITION
The final resting place for the cremated remains at'it e cs:.easerl
Given to her husband Michael Dane
If the funeral director whose signature appears on i,<ae tr •F a cf tnii;,fh.ithorization Form is not the person authorized to receive the
cremated remains of the deceased from the crema o. y orovide: :;:lrt.:; information for that person or persons:
(Phone)
(Name) (Aycre:
If for any reason the person named above does no: a f; povss sio the cremated remains,
Pine View Crematory is authorized to give possession of
(Cremalcy
the remains to M B Kilmer Funeral Home by delivery in
(Funere r a .V
in person or via delivery by the United States Post r v ur, i c rr ,'led by its regulations and procedures.
DOS-1898-f(Rev. 01/23) Page 2 of 3