Tokos Irene GPine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: _ BgwG,q_ RETURN TIME: tjolrf_
DATE & TIME REMAINS ARRIVED AT CREMATORY:
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
NAME:
---___.—_ TO (COS —� CASE # S
TYPE OF CONTAINER: Sj{,pr1 hone tit
PLACE OF DEATH -
ESTIMATED WEIGHT OF REMAINS & CONTAINER700
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION: 9ilsl 13
TIME STARTED: �' TIME COMPLETED: _ 3;06
PLACED IN RETORT: �h --MOVED:—..
RETORT # IN WHICH REMAINS WERE CREMATED: S4EP. Fw
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SHALL 13E RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
,
NEW
YORK
STA E
Department of State
Cemeteries
Autnorezation for Cremation and Disposition
New York State
Department of State
DIVISION OF CEMETERIES
One Commerce Plaza
99 Washington Avenue
Albany, NY 12231-0001
Telephone: (518) 474-6226
This Authorization Form must be completed and signed prior to delivery of remains for cremation.
If this form is not properly completed or executed, the crematory may reject delivery of the human remains.
Date:1114113 Case Number: -�6 S
(for crematory use only)
Crematory Name:
Address:
Pine View Crematory
Quaker Road, Queensbury, New York 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 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 foreign 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.
IDENTIFICATION OF DECEASED
Name of Deceased: ('eY1e- Q , I Q k0 S Marital Status: ", Q "&
Last Known Address: '141 6 Grel2 s kc�t t rl. , �uxeev-s \0t-s 4 r \1 X Zge q
Place of Death: Municipality: 2Y\S Ql S >�a. State:
Gender: M �F E] X Aged `� DOB: (2 �° 1 of Z Date of Death: 11L6IZ4 K- Estim
❑ated Weight _
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.
DESCRIPTION OF CONTAINER IN WHICH REMAINS ARE BEING DELIVERED
Manufacturer or supplier: Starmark Material: Corrugated Box #38808
CREMATION CONTAINERIURN
(Initial ONE of the following)
i 1/We have provided Pine View Crematory
with an urn to be used as a container for the
(Name of Crematory)
cremated remains. I/We understand that if the um is too small to hold the entire cremated remains, an additional rigid
container may be used for delivery. Description of urn:
I/We have not provided an urn to be used as a container for the cremated remains, and understand that
Pine View Crematory
(Name of Crematory)
will place the cremated remains in
a rigid container for delivery.
DOS-1898-f (Rev. 06/23)
Page 1 of 3
.J
Authorization for Cremation and Disposition
PERSON IN CONTROL OF DISPOSITION
(Person(s) in control of disposition, initial ONE of the following)
I am/We are the designated agent of the deceased designated in a will or written instrument executed pursuant to Public
Health Law Section 4201.
-OR-
—i 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 Uwe 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:
Number: 3 Description:
2. The surviving spouse;
The surviving domestic partner;
3. Any surviving child eighteen years of age or older;
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.
(lnitia18OTH of the following)
I/We hereby affirm that the body of the deceased does not contain a battery, 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
to remove these items prior to cremation may result in harm to the crematory and crematory personnel.
7 I/We affirm that instructions have been given to Cassia Rafferty
regarding the removal of any personal property or other thing of value which an (Funeral Director J
y person signing below
or any family
member of the deceased wishes to preserve. Pine View Crematory
is not responsible for the removal of personal items from the container or frorm 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 OPT1OWZ) -"" - ` -- - - _ _ - ---- ----------=--
I/We 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.
Name of deceased::rc 2 ,(\-c G. 1 Q M S
DOS-1898-f (Rev. 06/23)
Page 2 of 3
Authorization for Cremation and Disposition
FINAL DISPOSITION
The final resting place for the cremated remains of the deceased is
® Placement in a grave, crypt, or niche at �!NC v't JLL'J
® Scattering as permitted by law (cemetery name)
® Other Returned to family-TBD
The person authorized to receive the cremated remains of the deceased from the cemetery is:
(Name) (Address)
(Phone)
1IM/e authorize the funeral director executing this Authorization Form, whose name appears on page 3 of this form, to receive
or send a representative of his or her funeral firm to receive the cremated remains on my/our behalf.
1 r any reason the person named above does not take possession of the cremated remains,
Pine View Crematory
(CrematoryNameJ is authorized to give possession of
the cremated remains to Baker Funeral Home
(Funeral Home Name)
in person or via delivery by the United States Postal Servic_ a as ermined by its regulationsand-procedures
` nl lal 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 an irretrievable man(Name of cremato
ner, as permitted by law.
This Authorization Form was provided by
Cassia Rafferty
(Funeral Director Name)
Baker Funeral Home
was executed at
(Funeral Home Name)
11 Lafayette Street, Queensbury, New York 12804
and is signed by the funeral director as witness to its executionyomeAddress)
I/We have received a completed copy of this Authorization Form.
I/We amlare 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 _ 1 & day of , 203 _
Lord 5 �0 L'o S
Typed or Printed Name
//�� /' I2 /' „,� 'Signaturei
Typed or Printed Name
Signature
Typed or Printed Name
Signature
WITNESS:
Cassia Rafferty `
(Funeral Director Typed or Printed Name)
#14100 L(Funeral Director Signature)
(Registration Number)
Name of deceased: -j:7%.,ne C . id o S
DOS-1898-f (Rev. 06/23)
Page 3 of 3