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Helms, Joseph A L�1 Pine View Cemetery & Crematorium Quaker Road Queensbury, NY 12804 (518) 745-4477 or (518) 745-4476 FUNERAL HOME: kcal RETURN TIME: rercony DATE & TIME REMAINS ARRIVED AT CREMATORY: ) III I ii ?%'o h NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS: NAME: 105G-'H Hams. CASE # S6 TYPE OF CONTAINER: ra)feks'lfc irtISGIET 4, - fens. - pks,_ PLACE OF DEATH: Lqlc'e YAKS 5 Cp. 401Pgl I y[ucavy) la ESTIMATED WEIGHT OF REMAINS & CONTAINER ISO J /1 is- `k $ccLl PLACED IN HOLD: PLACED IN REFRIGERATION: 2 I0fl DATE OF CREMATION: 111312 TIME STARTED: g` at) TIME COMPLETED: 1;go ir PLACED IN RETORT: MOVED: 1; OD 1 5' fIT? RETORT # IN WHICH REMAINS WERE CREMATED: Sv f I? (,( 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. a • New York State • • Department of State IVEW YORK Division of DIVISION OF CEMETERIES STATE OF ' One Commerce Plaza OPPORTUNITY. Cemeteries beries • ' 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. Date: 1(4 I 1,3 Case Number(for crematory use only):• s6 Crematory Name: Pine View Crematory • • • Address: c Q, pr .goari Q»PPnGbury, 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 arid 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 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: a--4S e j 4 / ' . • ile.77),5 Marital Status: •—�0(1/- • Last Known Address: e• d S 7"fir a e'il/ Neiv c ci/,A 1 "U.7. / Place of Death: L 4_ /''rat N /11/074—evnlft /1)€0 c/i4 • /1-y /a sd-- Gender: 11©F C X. Age„;_ __ DOB; 61/?d//970 Date of Death:119/'q/9404713 Estimated Weight:- O Description of casket/container in which remains will be delivered,including manufacturer or supplier and material. • Rai-eV"— )^�M1A I1e/l) eow'fiAl,1 el- . �i,u� ' i -cL PERSON IN CONTROL OF DISPOSITION • (Person(s)in control of disposition,initial ONE of the following) • I am • ted age t of eceas d de ' Hated a wi written i ment executed pursuant o . . • Health Section 1. -0R)/3tO • • • 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: • • DOS-1898-f(Rev.01/23) Page 1 of 3 Authorization for Cremation and Disposition (Insert from the list below) . • Number: /7 Description: areir r K • 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. . (hill OTH of the following) . /� /� I/We herebyaffirm that the bodyof the decease. does not contain - batte battery pack,power cell,radioactive implant,� rY plan, or radioactive device and that any such materia ,,- - r- - . -. . • o e 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 ,-1-27ILI r l ,( (Fun !rector Name) regarding the removal of any personal properly yor other thing of value which any person signing g 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. MN-, %-TIONAL) • - . /I/ All 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 . - • jI'r �4UCo n1 )`-� . . • I e fune -ctor who : : re appears on .-•- . ee of this Authorization Form is not the person - orized to receive the remated remains , -.deceased fr. '- ematory,pro •e .•• - for .ersons: (Name) . (Address) maw (Phone) 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 • (Cram& Name) / r-� the remains to ��d•>4 h APt 6/V IV -e 41 — ff- by delivery in (Funeral Home Na;rfe) in person or via delivery by the United States Postal Service,as permitted by its regulations and procedures. s • • DOS-1898-f(Rev.01/23) Page 2 of 3 Authorization for Cremation and Disposition • (/Hill a following) i/We understand that if the remains are not claimed within 120 days of cremation, Pine View Crematory may dispose ofthe.remains in (Name of Crematory) an irretrievable manner;such as by scattering. CREMATION CONTAINER/URN (Initial ONE of the following) I/Welha a wit n um be n Her f ematgd (Name of Cremat remai .The urn is describe s follows: • /We un tan at if the urn too all to hold the entire cremate re ins,an diti finer m y be use for delivery.' -O 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 was provided by i c 4A) tee—ay was executed at ((uneral Director Name) Fd01Af-LL - J��-// FVR,rral /1& OZ et- '/`��) (Funerallfom} )e�Nen�gr • /OM. � • / ✓/: (FuneralhHome 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,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. • Signed t is /( T day of r ( 20 te • ame ture S117 Typed or?led N�v � P� Q�/-1) // hI � Address p 7 Typed or Printed Name Signatum Address • Typed or Printed Name Signature Address • • WITNESS: AO • iee# (Funeral Director Typed or Printed Name) (Fun ds dorSignature) (Registration N mber) • DOS-1898-f(Rev.01/23) Page 3 of 3 .