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Swanson, William D Pine View Cemetery & Crematorium Quaker Road Queensbury, NY 12804 (518) 745-4477 or (518) 745-4476 FUNERAL HOME: _ _, RETURN TIME: f !uit UjD DATE & TIME REMAINS ARRIVED AT CREMATORY: g/S / jj f2:3(jm NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS: Pg. rututkz_ NAME: —.- kIyC A fl S G✓l(isOt) CASE # b37 TYPE OF CONTAINER: �4o2/ce rAse� Ij PLACE OF DEATH: /}28,1M1 fl(PLC At- 1E/4176Zy ESTIMATED WEIGHT OF REMAINS & CONTAINER Ii 1bs PLACED IN HOLD: 12:mf Il PLACED IN REFRIGERATION: DATE OF CREMATION: g I10I 73 TIME STARTED: I' 5 fl TIME COMPLETED: 3 Y r) PLACED IN RETORT: 1,70pn MOVED: ZIO Pr 2; SZj�h RETORT # IN WHICH REMAINS WERE CREMATED: Su-PE g_ wkit to 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 NEWYORK D • ivision of • • Department of State • 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 mutt be completed and signed prior to delivery of remains for cremation. Date: 915113 Case Number(for crematory use only): t 31 Crematory Name: Pine View Crematory • • Address: c1 Qr.mkpr Pearl Q»Pensbury, 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 and flame will incinerate and consume everything except bone and metal, which are all that wilt 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 fqreign 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 DECE, / ASE/D e f ' • I. Name of Deceased: tlJ. 1! nA • if E . .3 (,{�r'1 I(f 5(�'V • Marital Status: M P rf 1 Last Known Address: Pi) di) 1/3 2 ' C Wit?+J 4 / '7-70 • Place of Death: rl I b A N1 y t G.a! ee,rI rz- A t 41 A!U i )''• a Zo$ Gender: M.NI©F ID. Age,69 DOB.Cl�/G 9 j Date of Deat • 7 ,/ 'Estimated Weight; 716 Description of casket/container in which remains will be delivered,including menu cturer or supplier and material.. • PERSON IN CONTROL OF DISPOSITION ' • (Person(s)in control of disposition,initial ONE of the follows' • I am/We are esignate agen a deceased • in a will or written insfrume rsuant to Public • ea L ection 4201. -OR- • • I/We haveno 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. MylOur relationship to the deceased is as follows: • • • DOS-1898-f(Rev.01/23) Page 1 of 3 • • Authorization for Cremation and Disposition • (Insert fre list below) Numberf 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 reasonably.available. • (Initial BOTH of the following) I/We hereby affirm that the body of the decease does not contain a batte batter y pack,power cell,radioactive implant, or radioactive device and that any such materia were removed p o e execution of this Authors • • to remove these items prior to cremation may result' harm to the crematoryan crematoryAuthorization Form. Failure personnel. I/We affirm that instructions have been given to dor Name) regarding the removal of any personal'property or other thingof value which any (Funeral below person sign' 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. (Initial 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 --- 13 Vh A r. {,ml`' //Pr 5 ¢�r4-�/ • • If th nera 'recto e sin re appears on f this Authorisation Form is not the person authorized to receive the cr ated rema f the.deceased• m the crematory,provide ntact informs t person or persons: (Nam (Address) (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 • (Crematory,Name) • / • the remains to • a)A'► - ,kJ/.j FL),V Qr 4/ /�1/ e-- " by delivery in (Funeral Home Nerhe) 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 Authorization for Cremation and Disposition (MN the following) 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) rovided P o used as a container for thg_cremated-- • e of ory) r mains.The n is described as follows: • I/We u (stand tha 'f the urn is o mall to ho rs-eremat ce7�re ' roar-_ ..�'tt ti m ett"" �ay-be�us rde 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 was provided by Q'4Li • was executed at (Funeral dorName) / 21)CL)A 1-•%- Foy P C-frAe— / FuneVtiome Name) (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. 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 of the deceased. • Signed this day of dAfr—r- ,20 . S Ll S GlAA Vk o �LJ Q-t'- S o Typed or Waled Name Signature Rc' # 6l /-Po-14ersv, ILe. , Ny Iaz'(vo Address Typed or Printed Name Signature • Address • Typed or Printed Name Signature Address WITNESS. / Ad 40 J- /.4//), 11111 (Funeral Director Ty dd rP tadNpe) (Funeral Dire.•r alum) • (Registration Number) • DOS-1898-f(Rev.01/23) Page 3 of 3 .