Meelan, Edward A ICF)
Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: R. ID. 5 . RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: -07( I Z3 2)sIb fj
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
Wi.wigui 60 I (
NAME: -_ EL D ,M toil) CASE # Sy Z.
TYPE OF CONTAINER: 9 FICAL0 fAi(GT Go .
- ----- rrvyti4.-c1 A.w len"
PLACE OF DEATH: C6pur
ESTIMATED WEIGHT OF REMAINS & CONTAINER Ira gas /%9 scei.
PLACED IN HOLD:
PLACED IN REFRIGERATION: 2% <q17
DATE OF CREMATION: 7 Z Z- -zez3
TIME STARTED: 7 _ TIME COMPLETED:
//
PLACED IN RETORT: MOVED: / ,r. _
RETORT # IN WHICH REMAINS WERE CREMATED: C Jes � iT
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.
ti
Department of State
NEW YORK Division of DIVISION OF CEMETERIES
STATE Of rrAt
>✓"OPPOR1 Cemeteries 99
Ailnery,N/1i:31 G'iC,1
Tf Ir�nr .r t,:„'p,4!4 G:7i6;
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Authorization for Cremation and Disposition
This Authorization Form must be completed and signed prior to delivery of remains for cremation.
Date 07/18/2023 Case Number(for crematory use only) _
C renratory Name. Pine View Crematorium
P duress 51 Quaker Road Queensbury,.N Y 12804 Phone (518j_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 and flame will incinerate and consume everything except bone and metal,:
which are all that will be left after cremation.
F o rowing cremation,the crematory will take reasonable efforts to remove all of the remains and other material from the cremation
• cnarrrbei,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 foreign material, including dental work and implants,will be disposed of as permitted by law lee
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 nolding 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. Edward A. Meelan Marital Status Divorced
t ast Known Address 1 Butcher Bpi, Raquette Lake NY 13436
Place of Deaths Glens Falls Hospital, 100 Park Street, Glens Falls , NY 12801 ___
Genoer• ®M ❑F ❑X Age 75 DOB. 01/19/1948 Date of Death:___07/1812023 Estimated Weight __ 1•
53
Lescrption of casket/container in which remains will be delivered,including manufacturer or supplier and material
Buffalo Casket Company— Corrugated Cardboard
PERSON IN CONTROL OF DISPOSITION
r Person(s)in control of disposition, initial ONE of the following)
- I am1We are the designated agent of the deceased des ynated in a will of written instrument executed pursuant to Pt,nl
Health Law Section 4201
r
•
'1K
', _ r-r_— Je have no knowledge that the deceased executed a written instiurnent puusuant to Public Health Law Se,t,orr
a v/i!l containing directions for the disposition of his or her iemains and Uwe are the personts)having prior;tr undo,
Health Law Section 4201 and have the right to a,1horize cremation of the remains us the deceased My/Our :elatrJirship
to the deceased is as follows
_Authorization for Cremation and Disposition
(h)se,i horn the list below)
Number _ 3 Description Child
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 Ire ore:-•easerJ
8. A duly appointed fiduciary'of the estate,
9 A close trend or relative who has executed a written statement pursuant to Public Health Law Section 4201(7).
10 Al ch et tisca,officer of a county or a public administrator appointed pursuant to the Surrogate's Court Procedure Act
10a Ar\ other person who is acting on behalf of the deceased and who has executed a written statement pursuant to Public Healy,
L JWti ;.,ect,on 4201 t 1)
Fo, n.:mbers 3, 5 and 1 above,by signing,the person(s)signing this Authorization Form represent that they are signing on oehalf of a
majority of the members of this class of persons who are reasonably available.
(initial BOTH f the following)
if a''0e hereby affirm that the body of the deceased does not contain a battery,battery pack, power cell, radioactive rr<<•+ar:;
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.
. , e affirm that instructions have been given to_ _ Wendy M. Bulich _ _ _-
0 I
(r ne,a CHrecror Name)+legarding the removal of any personal property or other thing of value which any person signing below or any family
member of the deceased wishes to preserve. Pine View Crematorium _
(Crematory Naare)
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
i MOW OPTIONAL)
llwe 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
Return to family
If the funeral director whose signature appears on page three of this Authorization Form rs not the person authorized to receive the
cremated remains of the deceased from the crematory.provide contact information for that person or persons
(Name?_.—�---- ------- (ACO,essI (Pt o°'
If for any reason the person named above does not take possession of the cremated remains,
Pine View Crematorium is authorized to give posses r.'.
rc enmrury No,,,o;
t•.e rernains to Regan Denny Stafford Funeral Home by celNc'•\
„•,,,e.,r,1.,,,,•Nu„u
, rug ',nr 'Jr nc dri+very by 'lie iln+trd States Postal Service, as permitted by its regulations anti ProceOLres
I'J�.rc ��,} l
1.' S tIt98 f rlfev U112:1)
;Authorization for Cremation and Disposition
i
i Initial the fo1 wing)
INye understand that it the remains are not claimed within 120 days of cremation
Pine View Crematorium - --- may dispose of the remains it
an irretrievable manner, such as by scattering
CREMATION CONTAINER/URN
i tnrhat ONE of the following)
I/We have provided- Pine View Crematorium with an urn to be used as a container er fr,r the cremated
(Name of CrrmoMryi
remains The uin Is descnbed as follows
_ I/We understand that if the urn is too small to hold the entire cremated remains,an additional rigid container may be used
for delivery
-OR-
I e have not provided ar�urn to be used as a container for the cremated remains, and understand that
Pine View Crematorium will place the cremated remains in
0._
- - .--- (Nime of L'remakwy) ----
a rigid temporary container for delivery
This Authorization Form was provided by ______ Wendy M. Bulich _-_ _ was executed at
(Funeral Dewier Name)
Regan Denny Stafford Funeral Home
(fwrerel Nome Name)
53 Quaker Road, Queensbury, NY 12804
(Funeral Home Address)arid is signed by the funeral director as witness to its execution.
I;We have received a completed copy of this Authorization Form.
I/We 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 cr
deceased.
Signed this 18th day of July
aped a Periled Name ( i" um
A I t-`