Denton,Larry A Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: AKZAPDQX RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: II i13 )13 It of l
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
cm 114001
NAME: /1Y1 v ft OEOpd CASE # Y(Z
TYPE OF CONTAINER: I'I trilE Li(
(A72.0e,ofti) Oak
PLACE OF DEATH: 4 rc -fats f-losevik
ESTIMATED WEIGHT OF REMAINS & CONTAINER 200 u k
PLACED IN HOLD: I2''k1c Pr1
PLACED IN REFRIGERATION:
DATE OF CREMATION: ff f j I J111 i3
TIME STARTED: Ill
TIME COMPLETED: /;50 �n
PLACED IN RETORT: II�O MOVED:
RETORT# IN WHICH REMAINS WERE CREMATED: fvwCiL 1 iR
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
NEW Department of State
• i YEW Department of State DIVISION OF CEMETERIES
STATE One Commerce Plaza
Cemeteries 99 Washington Avenue
Albany,NY 12231-0001
Telephone:(518)474-6226
https://dos.ny.gov
uthorization 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.
te: 11/13/2023 Case Number: R I Z
(for crematory use only)
( amatory Name: Pine View Crematory
/ Press: 21 Quaker Rd., Queensbury, NY 12804 Phone: C E l g ) ( l gill
c tEMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
( emation is carried out by placing the remains of the deceased and the container holding the remains into a cremation chamber where
t: y are subjected to intense heat and flame. The heat and flame will incinerate and consume everything except bone and metal,
Ni ,ich are all that will be left after cremation.
F 'lowing cremation, the crematory will take reasonable efforts to remove all of the remains and other material from the cremation
c tuber, but some minimal dust and residue will likely be left behind. The crematory will separate incidental and foreign material from
t ' remains and the incidental and foreign material, including dental work and implants, will be disposed of as permitted by law. The
c 'mated renii:.iins will be mechanically pulverized into small pieces and placed into a designated container or urn. Cremated remains
c nerally are :ulverized until no single fragment is recognizable as skeletal tissue.
I ENTIFICATION OF DECEASED
I me of DeceL.sed: Larry A. Denton Marital Status: Never Married
[ _;t Known/‘*.:Liress: 30 Tripp Lake Rd.,Chestertown,NY 12817
F :e of Der:- Municipality: Glens Falls State: NY
( ,der: -X] 7 F EN Age: 63 DOB: 11/04/1960 Date of Death: 11/11/2023 Estimated Weight: Zt.3-
c 'ENING OF THE CONTAINER
crematory may only open the container holding the un-cremated human remains in limited circumstances, such as to confirm the
i otity of the. c'cceased or to ensure that no material is enclosed which might injure employees or damage the crematory property. If
F man rema;.-,:> are delivered in a container which is not suitable for cremation such as ceremonial or rental casket, the crematory will
r ,I:ire that r remains be moved into a suitable container before it accepts the remains. The opening of a container or the transfer or
r -'oval of r , :3ins will be conducted before a witness and will be done in privacy, with dignity and respect.
I SCRIPTICid OF CONTAINER IN WHICH REMAINS ARE BEING DELIVERED
F -uufactur supplier: Matthews Material: Deluxe cardboard
r MATIO ONTAINER/URN
( :,,al ONE r he following)
:e have provided with an urn to be used as a container for the
(Name of Crematory)
c•mated remains. I/VVe understand that if the urn is too small to hold the entire cremated remains, an additional rigid
(- itainer may be used for delivery. Description of urn:
_ _Ai' have not provided an urn to be used as a container for the cremated remains, and understand that
4 - Pine View Crematory will place the cremated remains in
(Name of Crematory)
a r ,jid container for delivery.
t 1898-1 ,v. 06/23) Page 1 of 3
i =ithoriz. :tion for Cremation and Disposition
RSON IN CONTROL OF DISPOSITION
rson(s)in_: intro!of disposition, initial ONE of the following)
r /We are the designated agent of the deceased designated in a will or written instrument executed pursuant to Public
I ,ith Law Section 4201.
OR-
have
no knowledge that the deceased executed a written instrument pursuant to Public Health Law Section 4201 or a
containing directions for the disposition of his or her remains and I/we are the person(s) having priority under Public
'• 00Ith Law Section 4201 and have the right to authorize cremation of the remains of the deceased. My/Our relationship
he deceased is as follows:
Description: Sibling
The surviving spouse;
The surviving domestic partner;
Any surviving child eighteen years of age or older;
A surviving parent;
A surviving sibling eighteen years of age or older;
A lawfully appointed guardian;
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;
A duly appointed fiduciary of the estate;
A close friend or relative who has executed a written statement pursuant to Public Health Law Section 4201(7);
. A chief fiscal officer of a county or a public administrator appointed pursuant to the Surrogate's Court Procedure
Act;
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).
F nun?bero and 7 above, by signing, the person(s)signing this Authorization Form represent that they are signing on behalf of a
r ;ority of th cembers of this class of persons who are reasonably available.
( DOTI • the following)
hereby affirm that the body of the deceased does not contain a battery, battery pack, power cell, radioactive implant,
dioactive device and that any such materials were removed prior to the execution of this Authorization Form. Failure
omove these items prior to cremation may result in harm to the crematory and crematory personnel.
14' - affirm that instructions have been given to John Alexander
(Funeral Director Name)
rding the removal of any personal property or other thing of value which any person signing below or any family
tuber of the deceased wishes to preserve. Pine View Crematory
(Crematory Name)
responsible for the removal of personal items from the container or from the remains of the deceased. Personal
left in the container or with the remains will be destroyed by the cremation process and cannot be retrieved
r cremation.
__'/iI OPT '')
_ hereby authorize the named funeral director to provide for delivery to and cremation by an alternate
atory, if deemed necessary in the opinion of the funeral director,and to amend this form to provide the
oct name and address of such alternate crematory.
Name of deceased: Larry A. Denton
C "iS-1898-r 06/23) Page 2 of 3
I -uthorization for Cremation and Disposition
'F JAL DISPi:3ITION
T :hI final rest .g place for the cremated remains of the deceased is
IJ Placeme in a grave, crypt, or niche at
Scatterir;as permitted by law (cemetery name)
VOther Return to family
(description)
1 e person r thorized to receive the cremated remains of the deceased from the crematory is:
..)ri Denton 30 Tripp Lake Rd.,Chestertown, NY
(Nair:•-; (Address) (Phone)
V...4
_ IA/ ,: authorize the funeral director executing this Authorization Form,whose name appears on page 3 of this form,to receive
or •_nd a representative of his or her funeral firm to receive the cremated remains on my/our behalf.
It )r any rea : n the person named above does not take possession of the cremated remains,
Pine View Crematory is authorized to give possession of
(Crematory Name)
ti cremate . tmains to Alexander-Baker Funeral Home
(Funeral Home Name)
it Jerson or delivery by the United States Postal Service, as permitted by its regulations and procedures.
If'.'e understand that if the remains are not claimed within 120 days of cremation,
Pine View Crematory
(Name of Crematory)
ty dispose of the remains in an irretrievable manner, as permitted by law.
T s Author' • tion Form was provided by John Alexander was executed at
(Funeral Director Name)
-
Alexander-Baker Funeral Home
(Funeral Home Name)
-
3809 Main Street,Warrensburg, NY 12885
(Funeral Home Address)
a i is signer' y the funeral director as witness to its execution.
I/ .e haver ived a completed copy of this Authorization Form.
Ii e am/a: : ; e person(s) in control of disposition,who by signing this Authorization Form, attest(s)to the accuracy and
c ,n pletenes of the information contained in this Authorization Form and hereby authorize(s)to cremate the remains of the
d .eased.
S ned this 13th day of November 20 23
Lori A. Denton
T J or Prim. Signature
30 Tripp Lake Road, Chestertown New,Yor_ 817
4
T. !J or Printe,J+�!;, Sign ure
7 orr;c
Signature
V TNESS:
John Alexander
(i- arai Direct - ::'or Printed`Vane) une - r Si ____�10036
(i _arotr
Name of deceased: Larry A. Denton
C S-1898-f ev. 06/23) Page 3 of 3