Francis, Russell Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: rd'(N�G`Q. RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: (0 13 1 73 2`'Oh
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
Olaf: Kp os�
NAME: L VOA or- CASE # 1 l I
TYPE OF CONTAINER: Fiu2- CA.Se gyp, Pz
/A/2413bAQE:).
PLACE OF DEATH: 21 AIR-Pd G z)s./I IA IG 6 f-I Ct.. t 17 I i`
ESTIMATED WEIGHT OF REMAINS & CONTAINER 7f'Q [ e
PLACED IN HOLD: 3;aQPr
PLACED IN REFRIGERATION:
DATE OF CREMATION: I0I4 1 Z3
TIME STARTED: 7,7f TIME COMPLETED: /0: IV it/
PLACED IN RETORT: 1;Hb P11 MOVED: g-'3a f 9..05 t ' 7'•
RETORT# IN WHICH REMAINS WERE CREMATED: urr-� i pr ' il,
T�
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.
Ne Vett•Stale
NE.W
YORK Department of State De—rtrne .
< Sate
DIVISiON •F CE.Ji Mof
IMS
o,e Co k'tce Aala
STATE Cemeteries
i i
99' astington Avenue
A.,ny,rly •• 31001.
Tele. ;.np:(61:i 474.6 26
http0S•CY..gov
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Authorization for Cremation and DisOosition.
This Authorization Perin must be completed and signed prior to delivery of remains for cremation.
If this form Is not property completed or executed,the crematory may reject delivery of the human remains.
Date:09/21/2023 ,
Case Number )I i
(forcrerniteriuse use. i
Crernatt. Name:Pine View Crematory
Address:21 Quaker Road,Qu,ensbury NY 12804 Phone:51a-70-4477
I ,
CREMATION IS AN IRREVERSI:LE AND FINAL PROCESLI
Cremation le carried out by placing the remains of the deceased and the container holding the remains into a cremation :albs whece
they are sObjebted to intense has and flame The heat and flame Mil Incinerate and consume everything except. , = an. me 'I,
which are all that will be left a ,r orentaflon. i
Following cremation,the cremato will take reasonable efforts to remove all of the remains and other Material from the • F rnatio
chamber but some minimal dust rid residue wilt likely be left behind, The crematory will separate Incidental and foreig 1 rriateri,, fro ...
the remains and the incidental an foreign material,including dental work and implants;Will be disposed of as permitted ;,y law. 1 :
cremated remains will be mechan early pulverized into small pieces and placed into a designated container or urn. Ore ,fed re at
•generally are pulverized until n. single fragmerit is recognizable as skeletal tissue- ,
IDENTIFIcATION OF DECEASE l'•
Name:of Deceased: Russell Fra cis
Marital Status: DiVd 1 ad
Last Known Address:2220 Durh-m Road,Maidson CT 06443
Place of Death:Municipality,Lake Placid Airport,27 Airport Lane;.Lake Placid, NY 12946
-01.-2023 State: MY
,
Gender kft 11
i M 3Fgx Age; ° DoB;0+03-1953 : Date cif Death: 10 Estimated. .'.911t. - I-0
OPENING OF THE C9NTAINER
The crematory may only open the i••ntainer holding the un-cremated human remains in limited circumstances,such as to • fimi • e
identity of the deceased or to ens -.::that no material is enclosed witich might injure employees or damage the crematory 'rope If
human remains are delivered in a •ntainer which is not suitable for cremation:such as ceremonial or rental casket the c -matoryl ill
require that the remains be MOVed i to:a suitable container before it accepts the remains.The opening of a container or ..: trans r or
removal of rema iris will be cond .•:before a witness and will be done in privacy,with dignity and respect_
DESCRIPTION OF CONTAINER I VI(HICH REMAINS ARE BEING DELIVERED
Manufacturer or supplier;
Minumu . Material:
Cremation Casket . Florence Casket Co.Cardin-x:4 qPide
CREMATION CONTAINEFt/DRN
(Initial ONE ofthe following)
Pine View Crematory
be have provided with an urn to be used as a canto' er for e
Maine of Creinatcgy)
cremated remains;INVe understand that if the Om is tOo Small to hold the entire cremated.remaina,an.additio ,I rigid
container may be used for delivery.Description of 011.13,
-OR-
dik"--- IAN&have not provided an:urn to be used as:a container for the cremated remains,and.understand that
'x''" Pine View Crematory
will place the qemated ,:mains'n
fNene ofcrematonA
a rigid container for delivery,
DOS-1E98-f(Rev,OS/23)
P.,'•e I a
Authorization for C emation and Dis.•Osition NMI
P RSO I. C. TR. . ,
'O TiON.
(Person(s)In control ofdisp4sftlo ;.initial OI1lE of the following
. I arniWe are the des•stated agent of the deceased designated in a will or written instrument executed purs ant.to bite
Health Law Section 201.
-OR
ka- 1ANe have no.knowleege that the deceased execut d a written instrument pursuant to Public Health Law ti i will containing directir ns for the disposition of tits.or her remains endUwe are the der Pu 9 ore
Health Law Section r 04 and have the tight to au ,oriZe Cremation of the remains of the deceased priority u tlo•tic
to the deceased is = 'follows; MyiQu ;relatio sh
Number:2a.. Description:Th; surviving domestic partne
2. The surviving spouse;
2a. The surviving domestic.partner,
3. Any surviving. hild eighteen years of age o older;.
4. A surviving p rent;
5. A surviving Si•ling eighteen years o€'age or wer;
6, A lawfully app.inted guardian;
7. Any Person(s)eighteen years of age or older entitled to share in the estate and who is/are closest in elatio ip t.
the deceased;
8, A duly appoint-d fiduciary of the estate;
9. A close friend sr relative who has executed a Written statement pursuant to Public Health Law Sectio 4201(7);.
1.0. A.chief fiscal.. cer of a county or a public Idrninistrator appointed pursuant to the Surrogates Court rocedtl re:
Act;
1 Oa. ,Any ether•.pe •n who is acting on behalf of he deceased and who has executed a written statement i ursua .to
Public:Health .wSection420.(7).
g ng,. p ( }signing For numbers 3,5 and 7 above,by •i ni the person(s)s si nrn is Authorization Form represent that they are signing o behalf.f a
majority Of the members of this cla-s of persons who are reason y available.
(Initial.BOTH•of the following)
HWe hereby affirm that e body of the deceased does not.contain a battery,.battery.pack,power cell, radioa a im .l_n
>)+, .. N p t,
or radioactive device a d that any such materials we removed prior to the execution of this Authorization •rm, F ure
to remove these Item= prior to Cremation may re uit in harm to the crematory and crematory personn I.
Ark, I/We affirm:that instruct one have been given to Katie Morehouse
regarding theremoval an•f (PonerarOrrecrorNeine.
Y personal property or other thing value which any person.signing below or any.{ Hy
member of the deceas>• wishes to preserve. Pine View Crematory
(Crest atoiyrrame)
is not responsible for th•removal of personal items from the Container or from'the remains of the deceased.. •rsona
items left in the.contai er or with the remains Will be destroyed by the cremation process and cannot:. retrie ,ed
after cremation.
(Initial OPTIONAL)
I/We hereby authorize t named funeral director to provide for delivery to and Cremation by an alterna crematory,If deemed ecessary In the opinion Of the funeral.director,and to amend this form to provid the
correct name and add -ss of such alternate crem Mary.
Name of deceased;Russell:Francis
I.
DOS-1898-f(Rev..06/23) I :
Pa e 2 of 3
Authorization.for Cremation and Dispoiiition.
FINAL DISPOSITION
The final resting place for the cremated remains of the deceaseds
O P(acemeritin a(*aye,crypt, or niche at
(ceme1iy name)
El Scattering AS permitted by law
la Other Given to Jaclyn Ryan
description)
The person authorized to receivetha cremated remains of the deceased from the cemetery is:
Katie Morehouse 82 Broadway,Fort Edward NY 1282a 518-747-!266
(Nahle) (Address)' 4P •
Me authorize the funeral director executing this AuthOrization Form,whose name appears on page 3 of this to ,to receive
or send erepresentative of his or her funeral firm to red:A ive the cremated remains on mytout behalf..
if for any reason the person named above does not take possession of the cremated remains,
Pine View Crematory is authorized to give assessiOn of
(Crenratmy Name)
M.B..Kilmer Funeral Home
the cremated remains to
ftgoAra(egme Naito)
in person or via delivery by the United States Postal Service,as permitted by its regulations and procedures.
(Initial the following)
.01teC;/We understand thatif he remains are not claimed within 120 days of cremation;
Pine View Crematory
ohime dcrematoiy)
may dispose of the remains in an irretrievable manner,as permitted by law.
Morehouse
This Authorization Form was provided by Katie was ecuted at
(Funeral DIrectorNamel
M.B. Kilmer Funerat Home
(Funeral Heitz Nem)
.82 Broadway, Fort Edward NY 12828
(PuMeel Korea Address)
and is eigned by the funeral director as witness to its execution.
1Mte:have received a completed copy of this Authorization Formi
tiwe am/are the person(s)In control of disposition,who by.signing this Authorization Form,attest(s)to the acc and
completeness of the information contained in this Authorization Form and hereby authorize(s)to cremate the re of the
deceased.
Signed this 3rtf . day of Oc ober io 23
jzs
Jaclyn Ryan t RAI c .3
'Typed or Prieteg Name zr
2220 Durham Road,Madison CT 06443 ,
Aektivas
Typed or/3440d Name SIVnalure
Address •
Typed or Printed Neine S1riernie
"kr)Ores s
WITNESS:
Katie Morehouse
(Foust&Directortypeil or Printed-Name) -101 • Signature)
149511
(1ke:eisfM1ion Nem*,
Russell Francis
Name of deceased:
D0.8718984(Rev.06123) P;ge 3 of,3