Tuma, Patricia CF)
Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: Hcf it14,0ijL RETURN TIME: iOd�'F_
DATE & TIME REMAINS ARRIVED AT CREMATORY: II Il 1/3 11'404n
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
DAuC p`kv 1100
NAME: e tTR1CrA ToilA CASE # cg-)f
TYPE OF CONTAINER: PUF4Alb fASC kit `p _ /j411
O_S . R-
PLACE OF DEATH: q:Nt fi4 Lt S His PT.P /J
ESTIMATED WEIGHT OF REMAINS & CONTAINER /Sb iL /'c?
Q
PLACED IN HOLD: 1I:70 01
PLACED IN REFRIGERATION:
DATE OF CREMATION: // 4/ZVZ 3
TIME STARTED: r„L TIME COMPLETED:
PLACED IN RETORT: a
MOVED: 1 _
RETORT# IN WHICH REMAINS WERE CREMATED: Per P14k I'
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 PERMAN 4T FILE OF THE CREMATORY.
New York State
Department of State
NEW
Department of State DIVISION OF CEMETERIES
Y�--� STATE One C ue
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 11/01/2023 Case Number:
(for crematory use only)
Name Pine View Crematory
Add s:; 21 Quaker Rd.,Queensbury, NY 12804 Phone: (TIT) I-t�115
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Crer rrticm is carried out by placing the remains of the deceased and the container holding the remains into a cremation chamber where
they : 'e ,ub;ected 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.
Folio . remation. the crematory will take reasonable efforts to remove all of the remains and other material from the cremation
char ::=r 1-)Lit some minimal dust and residue will likely be left behind. The crematory will separate incidental and foreign material from
the u- r.r'ri , nR11 the incidental and foreign material, including dental work and implants, will be disposed of as permitted by law. The
ernains 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
Nang Deceased: Patricia Tuma Marital Status: Married
Last re.,,:,e/.een `address 2764 State Route 28, North Creek,NY 12853
Plac_� [ ath Municipality: Glens Falls State: NY
L N F n x Age: 65 DOB: 08/21/1958 Date of Death: 10/31/2023 Estimated Weight: 150
OPENING OF THE CONTAINER
The c ralory' may only open the container holding the un-cremated human remains in limited circumstances, such as to confirm the
ides r t the deceased or to ensure that no material is enclosed which might injure employees or damage the crematory property. If
huma m e,rains are delivered in a container which is not suitable for cremation such as ceremonial or rental casket, the crematory will
req nr t,:t the remains be moved into a suitable container before it accepts the remains. The opening of a container or the transfer or
rein - remains will be conducted before a witness and will be done in privacy, with dignity and respect.
DESCRIPTION OF CONTAINER IN WHICH REMAINS ARE BEING DELIVERED
Mar !_er or supplier: Buffalo Casket Material: Cardboard/OSB
CREMATION CONTAINER/URN
(Intl :0%the following)
Irwe have provided with an urn to be used as a container for the
(Name of Crematory)
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:
H.Ne have 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)
a rigid container for delivery.
DC: r der 06/23) Page 1 of 3
Authorization for Cremation and Disposition
PERSON IN CONTROL OF DISPOSITION
(Persc,�(sj in control of disposition, initial ONE of the following)
I amlVVe are the designated agent of the deceased designated in a will or written instrument executed pursuant to Public
Health Law Section 4201.
_ I Vve have no knowledge that the deceased executed a written instrument pursuant to Public Health Law Section 4201 or a
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„vnll 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 the deceased is as follows:
Nun':a 2 Description: Surviving Spouse
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 , A ''.b'rs,3 5 and 7 above, by signing, the person(s)signing this Authorization Form represent that they are signing on behalf of a
major it at the members of this class of persons who are reasonably available.
(lnar, ->( , of the following)
_ ,lve hereby affirm that the body of the deceased does not contain a battery, battery pack, power cell, radioactive implant,
(2.,
radioactive device and that any such materials were removed prior to the execution of this Authorization Form. Failure
Rtto remove these items prior to cremation may result in harm to the crematory and crematory personnel.
!Mie affirm that instructions have been given to David Alexander
(Funeral Director Name)
'gardrng 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. Pine View Crematory
(Crematory Name)
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.
(lnrtra,_ rr'i i'••)IVAL)
_______ IiiNe 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: Patricia Tuma
DOt 1 Mi: 1:key 06123) Page 2 of 3
Authorization for Cremation and Disposition
FINAL DISPOSITION
The final resting place for the cremated remains of the deceased is
LiPlacement in a grave, crypt, or niche at
(cemetery name)
D :Scattering as permitted by law
D (_.,the, Return to family
(description)
The person authorized to receive the cremated remains of the deceased from the crematory is:
(Address) (Phone)
__R I Ve. authorize the funeral director executing this Authorization Form,whose name appears on page 3 of this form,to receive
cr send a representative of his or her funeral firm to receive the cremated remains on my/our behalf.
If for my 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 c:: rr te : remains to Alexander-Baker Funeral Home
(Funeral Home Name)
in per son or oa delivery by the United States Postal Service, as permitted by its regulations and procedures.
(//h,,.;i; tt ie Lj,rm"log)
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it-We understand that if the remains are not claimed within 120 days of cremation,
Pine View Crematory
(Name of Crematory)
may dispose of the remains in an irretrievable manner, as permitted by law.
Thus Authorization Form 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)
and rs s,yn:•c; by the funeral director as witness to its execution.
I/Vv_= r i,e re,.:eived a completed copy of this Authorization Form.
IMie em/are the person(s) in control of disposition,who by signing this Authorization Form, attest(s)to the accuracy and
corn pieteness of the information contained in this Authorization Form and hereby authorize(s)to cremate the remains of the
deceased.
Signed this 1st day of November , 20 23
Robert J. Tuma , / g 'c1
7 r, Signature 9
2764 State Route 28, North Creek, New York 12853
Ads:.
Signature
Ar
7r-;: - --- Signature
Ad,:::._ -
WITNESS:
David Alexander
(F -rJamut ,rectorSigne
10034
(F,.
Name of deceased: Patricia Tuma
DOS-I0(18,-t ;Rev 06/23) Page 3 of 3