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Fifiedld, John P F Pine View Cemetery & Crematorium Quaker Road Queensbury, NY 12804 (518) 745-4477 or (518) 745-4476 FUNERAL HOME: � LC�( RETURN TIME: DATE & TIME REMAINS ARRIVED AT CREMATORY: 7 1 ZG 1 Z3 2 r 3'P9 NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS: NAME: -- — f7150,0 _._ CASE # t oc TYPE OF CONTAINER: Fae6Na 06eor iIt.t. Ra3-- --- -- x�Ro PLACE OF DEATH: aft* Fill./ tlbsrvik ESTIMATED WEIGHT OF REMAINS & CONTAINER 14, / 330 /I s s� PLACED IN HOLD: PLACED IN REFRIGERATION: 2 %ycPP DATE OF CREMATION: .71 77113 TIME STARTED: 30 etn TIME COMPLETED: 1/ a0 4/1 PLACED IN RETORT: 1. 76' i I r 1 MOVED: /0;10 Lio4 1 j//:001 RETORT # IN WHICH REMAINS WERE CREMATED: fow►=z PR le it ((S1 DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS 1I1 FROM TIME OF ACCEPTED DELIVERY: NOTE: THE CREMATION LOG SHALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY. • • New York State • DIVISIONN i.,,rNEW PORK Division o f D of S 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 mutt be completed and signed prior to delivery of remains for cremation. Date: 1124113 Case Number(for crematory use only): 60© Crematory Name: Pine View Crematory • • Address: c Q,tWkpr earl Q11 sbury, NY T2804 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 arid flame will incinerate arid 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 fgreign 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: dhot, P. A' //e fc/ • • Marital Status:d/uorc.a—ck • Last Known Address: g/ to6crc�,ucr ' 4.. /UPaVc.po 6 N Place of Death: Ciea S i►// /i TA/ 141r K S7' '/oas 'gyp/4 'i i y, Gender: larM©F El X. Age: DOB;/2.4.t/IC!7/ Date of Death: / '°?`'t—3e# Estimated Weight;V-4*30 Description of casket/container in which remains will be delivered,including manufacturer or supplier and material.. ��,��� t T a& • 6 t laPr iv ova PERSON IN CONTROL OF DISPOSITION (Person(s)in control of disposition,initial ONE of the following) • • • e the gnate gents a dace d desi edin a will rw' nstrum uted abut; • ealth Law ion 4201. -7•1 ' I/We have•no knowled a that the deceased executed a written instrument pursuant to Public Health Law Section 4201 or • 9 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 •Authorization for Cremation and Disposition (Insert fro 'st below) . •"1 M Number: Description: � �� 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 reasonabiyavailable. . (`Inritial BOTH of the following) - V I/We hereby affirm that the body of the deceased o of contain a batter 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• {4• to remove these items prior to cremation may result inharm to the crematory and ' crematory personnel. �.O Y I/We affirm that instructiohs have been given to aCl V .f eel (Funeral Director Name) regarding the removal of any personal property or other thing of value which any per on signing below or any family member of the deceased wishes to preserve. Pine View Crematory• (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) . 1 e hereby ut rize th ame mere irector to provide f livery to and cr anon by an alternate rematory, eemed nec ss in the op ' n of the etal direc and • a end rovl6e h 'correct name and address f such alternate crematory. FINAL DISPOSITION The final resting place for the cremated remains of the deceased is .4. • RL7;l /J 72 FA mil,(,/ . If the ne 'rector whose signature a ears on page three this Authorization Form is not the person auth 'zed to receive the crre ated rem ns o . ce d•from t emato ovide con t inf a on that per or pe s: • ! (Name) d ) / ` (P one) I. or any reason the perso amed above d not take possessierr the cremated r airs, Pine View Crematory is authorized to give possession of • • f ./ (Crematory Name) L f • . the remains to R A r� 4.• 1��i 1'+�Npri'l IIG�"— by delivery in (F era/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 1`. Authorization for Cremation and Disposition • (Initial the following) _Elk,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 CONTAINERIURN (Initial ONE of the following) I/W have provide • ' a = ' . - „ with an be used as a containerfor the cremated ' (Namtatory) r ins.The urn i escribed as follow . j' I/We derstand that if t urn is too small to hold th entire cremated r a dditionelligid containecmay.be used for de ery. � -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 place the cremated remains in (Name of Crematory) a rigid temporary container for delivery. This Authorization Form w s provided by ..:•-6 NK1 L l was executed at (Funeral Director Name) SI CO III+A_ L, . l vkervi I Me— !V L Q U S /�.r / �r/daIHomelVrimia / L -7O LL (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. IIWe 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 .2 /'i1 day of 20 ?3 . • Vjoirot-i- WA-41:1-d 4 7;40.6? Typed or Printed Name Signature eeldtfio Adi& Ate/Ile A/. X /L�1/45-2, Address • Emily F1 4144 `) 14.1 Typed or Printed Name Signature -16 SQr; V� S}ree..+ Newcomb, NY 12652 Address Typed or Printed Name Signature • • Address • WITNESS: • 1/34,0 (Funeral Director Typed or Printed Name) (Funeral= • Signature) 1C� • (Registration Nu ber) • DOS-1898-f(Rev.01/23) Page 3 of 3