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Gurney, James E q.11/ Pine View Cemetery & Crematorium Quaker Road Queensbury, NY 12804 (518) 745-4477 or (518) 745-4476 FUNERAL HOME: PENa►vIrE RETURN TIME: DATE & TIME REMAINS ARRIVED AT CREMATORY: /0/3I 17 /:OoT NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS: NAME: MA M ES CORM l CASE # 913 TYPE OF CONTAINER: MATiniti3r RveO,o./} CinmQA µ1 u©eD A+ PLACE OF DEATH: ?S wi4Olo 5'rR-f,vr,l 14Pi ft + 0 it9nSl3 i C1l / IZ`!OI ESTIMATED WEIGHT OF REMAINS & CONTAINER Os- /I,$ stgAt PLACED IN HOLD: I:Ze PLACED IN REFRIGERATION: DATE OF CREMATION: ID (3( TIME STARTED: ( : ID Pr) TIME COMPLETED: 2;rspo� PLACED IN RETORT: ): 3 Qh MOVED: Z;ID-fin 2;M0PV7 RETORT# IN WHICH REMAINS WERE CREMATED: ft:IN1it rykti1V DETAILED REASON FOR DELAY IF REM AINS 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 arbnent of State " Department of State o F CEMETERIES One Commerce Plaza t STATE Cemeteries 99 Washington Avenue Albany.NY 12231-0001 Telephone:(518)474-6226 httpsJ/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:10/31/2023 Case Number: g13 (for crematory use oily) crematory Name:Pineview Crematory Address:21 Quaker Road,Queensbury, NY 12804 Phone: (SiIS l- `err 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,induding 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 with no single fragment is recognizable as skeletal tissue. IDENTIFICATION OF DECEASED Name of Deceased:James E.Gurney Marital Status Never Married Last Known Address:25 Durand Street,Apt.A, Plattsburgh, NY 12901 Place of Death:Municipality:25 Durand Street,Apt.A, Plattsburgh State: New York Gender: ©M D F D X Age:27 DOB-12/11/1995 Date of Death: 1029/2023 Estimated Weight' le --. 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 rnntainer before it accepts the remains.The opening of a container or the transfer or removal-of renainswill-be-conducted before-a wit ss-and-will-betel rb'�iein privacy,hi th dignity and iesped:- -- DESCRIPTION OF CONTAINER IN WHICH REMAINS ARE BEING DEUVERED Manufacturer or supplier Matthews Aurora Company Material:Wood&Cardboard Cremation Container CREMATION CONTAINER URN (j ah' 1 ONE of the following) I/We have provided Pineview Crematory vnlh an urn to be used as a container for the ANamoolO•aMWr1 cremated remains. I/We understand that if the urn is too small to hold the entire cremated remains,an additional rigid container may be used for delivery.Description of urn:Urn to be decided on a later date OR- '��__ ` IMfe have not provided an urn to be used as a container for the cremated remains,and understand that Pineview Crematory will place the cremated remains in adameo►Crematry) a rigid container for delivery. DOS-1898-f(Rev.08/23) Page 1 of 3 • 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- ,.-..);.-- id IMIe 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. tllylOur relationship to the deceased is as follows: Number. 4 Description:A surviving parent 2. The surviving spouse; 2a. The surviving domestic partner; 3. My 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 dose friend or relative who has executed a written statement pursuant to Public Health Law Section 4201(7); 10. A thief fiscal officer of a county or a public administrator appointed pursuant to the Surrogates Court Procedure 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. ( ate_ BOTH of the following) 1 >C 4i WUe 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 f to remove these items prior to cremation may result in harm to the crematory and crematory personnel. >4%jta I/We affirm that instructions have been given to Robert I.Densmore (Karmen OrredarName) regarding the removal of any personal property or other thing of value which any person signing below or any family member of the deceased wishes to preserve. Pineview Crematory (CremsloryName) 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) UWe 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:James E Gurney 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 1 Placement in a grave,crypt,or niche at 'r,` ra k,t` El (cemetery name) Scattering as permitted by law Other (fin) The person authorized to receive the cremated remains of the deceased from the crematory is: Robert I. Densmore 7 Sherman Avenue,Corinth, NY 12822 (518)654-9285 .,xliztt ) (Address) (Phone) • I/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 for any reason the person named above does not take possession of the cremated remains, Pineview Crematory is authorized to give possession of remmalory Name) the cremated remains to Densmore Funeral Home, Inc. -- --_ (Funeral Home Name) in person or via delivery by the United States Postal Service,as permitted by its regulations and procedures. •I the following) .> 4/Y. UWe understand that if the remains are not claimed within 120 days of cremation, Pineview Crematory (Narne of Crematory) may dispose of the remains in an irretrievable manner,as permitted by law. This Authorization Form was provided by Robert I. Densmore was executed at (Funeral Diredor Name) Densmore Funeral Home, Inc. (Funeral Home Name) 7 Sherman Avenue,Corinth, NY 12822 (Funeral Home Address) 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,attests)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 MIS 31 ct day of October 20 23 1Cy Grace Ann Gurney . Typed arR N Printed 9 /�d1Y `_ 4/"-/-" 604 Valley Drive,Americus,GA 31709 Address Typed w-I Panted Name - sgra(we Address Typed or Printed Name Sgnafure Adhess WITNESS: Robert I.Densmore = - (Fenerai amour Typed orPrinted Name) guderai 10910 (Registration Number) Name of deceased:James E.Gurney DOS-1898-f(Rev.06/23) Page 3 of 3