Wachowski, Frederick •
Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: ELN RETURN TIME: I S M)
DATE & TIME REMAINS ARRIVED AT CREMATORY: 11 130 113 S i4'
IM
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
da 4J Fc Cy
NAME: FI(itPC-1;tk.: PAC it= CASE # /Oa
TYPE OF CONTAINER: Fto Pert E CA“cfxlJ
CO a tit+4-v%1 p 4't-WE C L,j (3-0(.
PLACE OF DEATH: IS 1 l EP- fikt teo-) 12,0119 MO t / L/ rt gcc
ESTIMATED WEIGHT OF REMAINS & CONTAINER (40 ab-
PLACED IN HOLD: 53; .{�y
PLACED IN REFRIGERATION:
DATE OF CREMATION: ,i %4. 3\ "2 3
TIME STARTED: 1-414 TIME COMPLETED: JD 0 i
PLACED IN RETORT: 7: P101 MOVED: 4:3' f 11 l 8' 14 rel
1111 RETORT# IN WHICH REMAINS WERE CREMATED: pk PA,k�" /)
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
Department of State DepartmentNOF CEMETERIES of S
YORK DIVISION OF
SATE one Commerce Plaze
Cemeteries 99 Washington Avenue
Albany,NY 12231-0001
Telephone:(518)474-6226
https://dos.ny.gov
Authorization for Cremation and Disposition
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: /'/jobs Case Number: f46
(for crematory use only)
Crematory Name: Pine View Crematory
Address: 21 Quaker Rd. Queensbury, NY 12804 Phone: 518-761 -8279
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: r e-t e,--, 1V1 c (' a- (:4 e, to 5 /4 jj Marital Status: �(p4P M
I- DI•F f e.6
Last Known Address: l 9 0 IJ '' /�i°//0 w' j2L I-)d j-1 K 1yk-{cl c aV kt . 1 s s'
Place of Death:Municipality: ,,) 6-PePlr IIp//il' ' I'U d 1^ L-c4. State: k.y•
Gender: gl M ID ®X Ages 7 DOB:0)1/i/i 90 Date of Death: !1/h 1 b2 t'f Peca...3Estimated Weight: Ara
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 WHICHH REMAINS ARE BEING DELIVERED
Manufacturer or supplier: Fk_OPC if- =i5.5 A 4 4 Material: c r R/Q C 1 J u e— j..,i)lJ
CREMATION CONTAINER/URN
(Initial ONE of the following)
I/W- \ ovided ' •ne View _ wit m to : sed •' ,�i• he
\ , m: . Crematory) - 'r -��!,remated re ins.I/We unde d that if =urn is too s all t• hold the tire rem- ed re ins,anTiF•A•
con 'ner •y be used for deli, .De '• ion of urn:
iiii--
I i_ I/We have not provided an urn to be used as a container for the cremated remains,and understand that
Pine View will place the cremated remains in
(Name of Crematory)
a rigid container for delivery.
DOS-1898-f(Rev.06/23) Page 1 of 3
•
Authorization for Cremation and Disposition
PERSON IN C•NTROL OF DISPOSITION
(Person(s) " ; of dispo '" initial ONE of the following)
d/ I am/W re the design ed ent of the de a es ed in a 't or wri 'ri`fuen ceaated pnrstiacattarPublTc
Health Law Section 42 .
�
1 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 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. My/Our relationship
to eeased is as follows:
/ I
Number: -Description: )�6 /1
r
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•f the members of this lass of persons who are reasonably available.
B•TH of the following)
lIL' I/We hereby affirm that the body of the deceased does not contain a battey,battery pack,power cell,radioactive implant,
Ir 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 crematoryand crematory personnel.
�� I/We affirm that instructions have been given to Jô'4 0 c� ` ��I L�
IF (Fun Director Name)
regarding the removal of any personal property or other thing of value which any person si ning below or any family
member of the deceased wishes to preserve.
Pine View
(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)
I/We here horize the ame neral director to rovid r delivery to d ton b an
creme ,if deemed ne ry in the opinion of eral director,an amend this f to provide
correct name and addre of such alternate cre ory.
Name of deceased: t'r eid t Q'c I o s l-),
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
El Placement in a grave,crypt,or niche at
(cemetery name)
0 Scattering as pedby law
K-Other l \e-!er vyv0-o (lie 6 A t 2_( GO A G4Q 40 S ) ^
(demon) ere Pi P 7i' v','
The person authorized to receive the cremated remains of the deceased from the cP is:
t Oti V t1 i� )(Z iv 11 g2_ Av.- / 7Xi 5-'1�''sP3, - i 77
(N: -) ( dress) (Phone)
X a r /We 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.
If 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 cremated remains to &to()t-'a 1, � t� -t�p ly' ' 1.34 rot/ ty OM1`'
(Funeral Home Name)
in person or via delivery by the United States Postal Service,as permitted by its regulations and procedures.
(In:,;-1 ,e following)
Xa, I/We understand that if the remains are not claimed within 120 days of cremation,
MPine View Crematory
(Name of Crematory)
may dispose of the remains in an irret'evable manner,as permitted by law.
This Authorization Form was pr vid by , 6 , . �I i was executed at
^ j v / J —(Funeral°�or Name)�� —
(Fu1 / 90<51PCT ✓' L f " neralHomeN �- /v_ • ):3-e--)0
(Funeral HomeAddrre`/ss)
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 am/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 ,20 I\ . /
liilikiikame Al 111 1 kl. 14.7'.4- iFIRP051 ) h i r—
Typed or Printed Name Signature
Address
Typed or Printed Name Signature
Address
WITNESS:
V h io A- 14/frName) (Funs or Signature)
jii:I
(Reparationa (
/
Name of deceased: `R-d er','- i< W Q'C /1 0 'k S " 1`
DOS-1898-f(Rev.06/23) Page 3 of 3