Newcomb, James K Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: ;ALELArOEQ RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: 1t 1131 Z3 12.30 fti
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
OOP f\C.EXAn1Df
NAME: IJ UC un1B CASE #
TYPE OF CONTAINER: BuV fAL O *GT- a. ro�flJ 7
A"b Qs-13
PLACE OF DEATH: tiCn,s f v lics fS.Tfc 1,
ESTIMATED WEIGHT OF REMAINS & CONTAINER 73° lit- ` (wGef
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION: 1( �3174
TIME STARTED: Ap TIME COMPLETED: Z.
PLACED IN RETORT: MOVED: / Sr 141, 2'27-fill 150cn
RETORT# IN WHICH REMAINS WERE CREMATED: S orEg -Fu'uice PAL(
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.
• 1
New York State
r NE4° Department of State
, Department of State DIVISION OF CEMETERIES
YOE(.. P
r*�`;..� One Commerce Plaza
Cemeteries 99 Washington Avenue
� . Albany,NY 12231-0001
Telephone:(518)474-6226
https://dos.ny.gov
/ thorizat or) for Cremation and Disposition
i his Authorization Form must be completed and signed prior to delivery of remains for cremation.
i; _!,is form is not properly completed or executed,the crematory may reject delivery of the human remains.
C 11/09/2023 Case Number: Ili
(for crematory use only)
( latory IJ,:me Pine View Crematory
F, ass: _ 21 Quaker Rd., Queensbury, NY 12804 Phone: Gig) It— gill
C _MATION IS ,.N H'REVERSIBLE AND FINAL PROCESS.
C nation is can c.cl c. it by placing the remains of the deceased and the container holding the remains into a cremation chamber where
t are subjected to Intense heat and flame. The heat and flame will incinerate and consume everything except bone and metal,
v ;h are all th,:,i `vi'i be left after cremation.
F ,ving cm::; nat 1the crematory will take reasonable efforts to remove all of the remains and other material from the cremation
c giber, bra_;or,, minimal dust and residue will likely be left behind. The crematory will separate incidental and foreign material from
th emains::r,d incidental and foreign material, including dental work and implants, will be disposed of as permitted by law. The
c ,ated rernm c. iil be mechanically pulverized into small pieces and placed into a designated container or urn. Cremated remains
g !rally ar.! pr: •:s.r:zed until no single fragment is recognizable as skeletal tissue.
II 'TIFICATIOr- DI: DECEASED
r of D James K. Newcomb Marital Status: Widowed
L <nov n, 'di 35 Hadley Rd.,Apt. 2,Stony Creek,NY 12878
F :of Dc: ::, i_ipality: Glens Falls State: NY
c ,c.�r: F1 ',r [ --''1 X Age: 72 DOE 07/06/1951 Date of Death: 11/09/2023 Estimated Weight: 230
( ,,I,IG _n ')NTAINER
nrema.c .. n ;nly open the container holding the un-cremated human remains in limited circumstances, such as to confirm the
i iy of med or to ensure that no material is enclosed which might injure employees or damage the crematory property. If
I :n rem: hc. ivered in a container which is not suitable for cremation such as ceremonial or rental casket,the crematory will
r r,c ll 1 ,t i s be moved into a suitable container before it accepts the remains. The opening of a container or the transfer or
r cal of r. ;-;,a: ,,v:H be conducted before a witness and will be done in privacy, with dignity and respect.
[ 1RIPTI C Ch.)NTAINER IN WHICH REMAINS ARE BEING DELIVERED
r :non. tier. Buffalo Casket Material: Cardboard/OSB
( ^CTi ' l-AINER/URN
( OfCE '1, .wing)
provided with an urn to be used as a container for the
(Name of Crematory)
'emains. I/We understand that if the urn is too small to hold the entire cremated remains, an additional rigid
may be used for delivery. Description of urn:
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)
tainer for delivery.
1 1 :3) Page 1 of 3
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�-ho z:�._�'r1 for Cremation and Disposition
F ;ON IN '.);: •R:7L OF DISPOSITION
( o,n(s)ir;cc! ,1 of disposition, initial ONE of the following)
<.rr ".: .ire the designated agent of the deceased designated in a will or written instrument executed pursuant to Public
I. :'. . L::w Section 4201.
_ ! . -r e no knowledge that the deceased executed a written instrument pursuant to Public Health Law Section 4201 or a
r ,ining directions for the disposition of his or her remains and I/we are the person(s) having priority under Public
I :w Section 4201 and have the right to authorize cremation of the remains of the deceased. My/Our relationship
ceased is as follows:
I e :.ription: Surviving Child
9. 7 he surviving spouse;
:le surviving domestic partner;
ny surviving child eighteen years of age or older;
surviving parent;
surviving sibling eighteen years of age or older;
i lawfully appointed guardian;
ny person(s) eighteen years of age or older entitled to share in the estate and who is/are closest in relationship to
t;,e deceased;
i duly appointed fiduciary of the estate;
close friend or relative who has executed a written statement pursuant to Public Health Law Section 4201(7);
chief fiscal officer of a county or a public administrator appointed pursuant to the Surrogate's Court Procedure
ct;
ny other person who is acting on behalf of the deceased and who has executed a written statement pursuant to
ublic Health Law Section 4201(7).
I lb, n: 7 above, by signing,the person(s) signing this Authorization Form represent that they are signing on behalf of a
1. , ; of 1 nk•-Is of this class of persons who are reasonably available.
(: 'O f, ;;owing)
(( _I :)y affirm that the body of the deceased does not contain a battery, battery pack, power cell, radioactive implant,
;,tive device and that any such materials were removed prior to the execution of this Authorization Form. Failure
r, ;0-e these items prior to cremation may result in harm to the crematory and crematory personnel.
---0If: n that instructions have been given to David Alexander
(Funeral Director Name)
in the removal of any personal property or other thing of value which any person signing below or any family
1the deceased wishes to preserve. Pine View Crematory
(Crematory Name)
;Donsible for the removal of personal items from the container or from the remains of the deceased. Personal
in the container or with the remains will be destroyed by the cremation process and cannot be retrieved
... .rn oration.
ny authorize the named funeral director to provide for delivery to and cremation by an alternate
y, if deemed necessary in the opinion of the funeral director, and to amend this form to provide the
.a me and address of such alternate crematory.
Name of deceased: James K. Newcomb
[ 1393-f , ,3) Page 2 of 3
s
thoriz8Jon for Cremation and Disposition
F L DISPOSnn:ON
l inal resting; riace for the cremated remains of the deceased is
I ,lacement iri 3 grave, crypt, or niche at
(cemetery name)
t scattering t- permitted by law
[her Return to family
(description)
erson a'irt -�t_. d to receive the cremated remains of the deceased from the crematory is:
Nerve (Address) (Phone)
(CD_ IMe '. FH<uize the funeral director executing this Authorization Form,whose name appears on page 3 of this form,to receive
or se ' a representative of his or her funeral firm to receive the cremated remains on my/our behalf.
I my reas:;• '_:ie ; arson named above does not take possession of the cremated remains,
Pine View Crematory is authorized to give possession of
(Crematory Name)
t >mated ,e , .;in; to Alexander-Baker Funeral Home
(Funeral Home Name)
i ;on c.r < _. y by the United States Postal Service, as permitted by its regulations and procedures.
e toUc-..
I/A.' ndr'rstand that if the remains are not claimed within 120 days of cremation,
Pine View Crematory
(Name of Crematory)
m<,H. .- ,;':ose of the remains in an irretrievable manner, as permitted by law.
-' tithed:. • =orm was provided by David Alexander was executed at
(Funeral Director Name)
Alexander-Baker Funeral Home
(Funeral Home Name)
3809 Main Street,Warrensburg,NY 12885
(Funeral Home Address)
signed `.r Mineral director as witness to its execution.
lave rec, completed copy of this Authorization Form.
,mia,e f., •.:on(s)in control of disposition,who by signing this Authorization Form, attest(s)to the accuracy and
leteness -r;o information contained in this Authorization Form and hereby authorize(s)to cremate the remains of the
.sed.
ad this _ ;�.11 day of November , 20 23 .
mantha A. Newcomb > 1 (ttk.Aehocau0
s
35 Hadley Rd., Apt. 3, Stony Creek, New York 12878
Printer:Ii s Signature
Signature
t, ri_SS:
David Alexander
.. i PJame) UO9fal
10034
Name of deceased: James K.Newcomb
1 1898-f(L:. ':'123) Page 3 of 3