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Gregory, Nancy Pine View Cemetery & Crematorium Quaker Road Queensbury, NY 12804 (518) 745-4477 or (518) 745-4476 FUNERAL HOME: 11,8 ttLµ ------__ RETURN TIME: DATE & TIME REMAINS ARRIVED AT CREMATORY: °I o/ r)7bD I/J NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS: NAME: - — ..— —N(3-"u(L kk 6.0e ---- -- CASE # TYPE OF CONTAINER: F'G0 ,Jc 1±q4 " -- — — CVgenG o (AIuJ�3c 1Q PLACE OF DEATH: gI file Z ESTIMATED WEIGHT OF REMAINS & CONTAINER /So A, 5,4 PLACED IN HOLD: PLACED IN REFRIGERATION: DATE OF CREMATION: ct 17D 173 TIME STARTED: /0:)S !I" TIME COMPLETED: 12 ; Qij PLACED IN RETORT: /0L I MOVED: ill O ir 12 f7 RETORT # IN WHICH REMAINS WERE CREMATED: Su fE R 10wE,a f4� 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. 9/18/23,3:52 PM Scan_20230918(2).png • 1 New York Stato Department of State ri—INEW j Department of :tate DIVISION OF CEMETERIES YORK One Ccmtnerce Pi STATE Cemeteries 99 Washirg:on Avenue ' Or , Albany,NY 12231-0001 Telephone:;518)474-6226 hltps:/kIcs.r.y.gov Authorization for Cremation and Disposition This Authorization Form must be completed and signed prior to delivery of remains for cremation. It this form is not properly completed or oxecuted,the crematory may reject delivery of the human remains. Date 08/27/2023 Case Number. 1 Oct-crematory use on y Crematory Name Pine View Crematory -- --- ________ Address 21 Quaker Road, Queensbury 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 will be left after cremation. Following cremation,the crematory will take reasonable efforts to remove ail 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 Decease..., Nancy Gregory Marital Status: Widowed u Last Known Acdress L._ , a.—... ,_) • -,—.1 I Place of Death.Municipality Essex Center. 81 Park Street,Elizabethtown State: NY Gender: Li M 0 F El X Age:82 DoB 12-22-1939 09172023 - - Date of Death. Estimated Weight,150 OPENING OF THE CONTAINER The crematory may only open the container holding the un-crernated 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 iertiovai of remains will be conducted before a witness and will be done in privacy with dignity and respect. DESCRIPTION OF CONT,INER IN WHICH REMAINS ARE BEING DELIVERED Minumurn Ore.mation Casket Florence Casket Co. Cardboard/Pine Mani.iincturor or suppiier Material,___CREMATION CONTAINER/URN 09141 ONE.:of the following) Pine View Crematory Imre have provIcied w.th an urn to be used as a container for the cremated remains. INIy 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 -CR- i,,,,,Ve havc,riot p.'ovidiA an urn to he used as a container tar the cremated remains and understand that Pine View Crematory ____ _____ with place the cremated remains in a rigid container for delivery DOS-1898-f::Rev 06/23; Page 1 of 3 1/1 htlps://mail.google.com/mail/u/0/?tab=rm&ogbl#inbox/FMfcgzGtxKPJGgzXnWPThzXlcbwMWdWL?projector=1 9/18/23,3:53 PM Scan_20230918(10).png • • • Authorization for Cremation and Disposition - PERSON IN CONTROL OF pISPOSITION (Person(s)in control of thsposibon, initial ONE of foe(ollovvii)g) I anliVVe are the desionated agent of the deceased designated in a will or wittier;instrument executed pursuant to Public Health Law Section 4201 -OR- INVe have no knowledge that the dece.rasee 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 perscn(s)having priority uncle!'Pubic 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.5 Des„,,,ption sibiing eighteen yearrii of age or alder 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 acre or older 6. A lawfully appointed guardian. 7. Any person(s)eighteen years of age or older entitled to shale in the estate and who islare closest in relationship to the deceased, 8. A duly appointed fiduciary of the estate: 9. A close friend or relative who has e‘xeciited a written starement pursuant to Public Health Law Section 420147), 10. A chief fiscal Officer of a county or a public administrator appe,nted 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 et a metority of the members of this class of persons who are reasonably available (initial BOTH of The followtogIIWe ) hereby aff)mt 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!c,the execution of this Authorization Form Failure to remove these items prior to cremation may result in harm to the crematory and crematory personnel. 1,We affirm that instruohons have been over:toKatie Morehouse • •• regarding the removal of any persona)properly or other tiring of value r.vhico any person siccing below or any farnOy Pine C member of the deceased wishes to preserve _ Viewrematory 0•701g1,) 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) 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. Nancy Gregory Name of deceased: . „ DOS-1898-f(Rev 06/23) Page 2 of 3 1/1 https://mail.google.com/mail/u/0/?tab=rm&ogbl#inbox/FMfcgzGtxKQPjvJFGjfZsgZxVtGQRnfm?projector=1 ^ 8n8/28.3:51 PM Soon_zV23O81o(^).png Authorization for-Cremation and Disposition FINAL DISPOSITION Placement in a grave,crypt,or niche at Pine View Cemetery �l I Z:M��"=" -- --- ----- ~. S�xnnmoo»e�io��/�� ~ El Other The pomonavmu,uemtn receive the"re'n*Eeure«.um,or the deceased m*/a----- — —'----- xa*iyMoehouse 828rnadwsy. Fort Edward NY 128)3 518'747'9266 /xm -' *^^^="` ------------- --- .p"��------- ev:moozemomnomiuneuo,exsvm.ngmsAuxorizauonponnr vvhnoanomo appears ou page um this form mecaive - vr send a representative^/his o,her fu,mra;oxnm receive the cremated renw"vonmvmu,behalf n for any reason the person named above does not take possession mme cremated remains, pioeVlewC,em�m -- � ��y /xov,xnrizmom give r,uuv,s.onm the oremateummainomm8 Kilmer Funeral Home -�� o`P�'5yxo' via ue//vmnoymoun.�eu ^s/a� spouu/uem/:e a °="''°'� = ------ ------- "vexvmeoo/.-,,,eyv/xovoo rm:^�u�� _/*vo Linde cnaro that/,the rewamv"re riot claimed wnmn12ouav^v/rmmauon. Pine View Cemato� may dispose v,me remains/nnn/nrmo,ame"`aono' uo permitted u/law This Authorization Form was provided uv ��UeMoehnuse _______________________ oxenmrua* M B. Kilmer Funeral Hmne .�LBmaUway. Fort Edward Ny�i�� _ anvmo/onemcymofun:ra/u/rec!ora,wom°eom/*oxc,.uon /mve�ave received^completed copy othis Authorization Form IfWe am/are the msn*omon who signing this Authorization Form,mmoat(s)vv the accuracy and completeness",the Information contained m this Authorization Form and hereby awmvnpp(u)tp cremate the remains p,the mmma000. Signed 18� Sept b on , -__- oavm�e��*xer�___________�.m 23 Richard Garand �s��n�w,^ ----� - - ----------- --' --- ^ 12017 Greenwa�pim|eS�t`APL20�_��8�Pam�8aach - ^-~� c�°^,"------------- --- -----' ---------' WITNESS: Katie - *ahemo"ohouoe -- 14951 m~.-.c...-.� 1 v1