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Nelson, Emma E Pine View Cemetery & Crematorium Quaker Road Queensbury, NY 12804 (518) 745-4477 or (518) 745-4476 FUNERAL HOME: A4jC4,,,ic1,v`' RETURN TIME: i.//, DATE & TIME REMAINS ARRIVED AT CREMATORY: /7=4._ //Z 2-zaZ3 NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS: kit/ it)IeVit NAME: 1�/Y//1a N4/66„J CASE # 9-37 TYPE OF CONTAINER: E -P I p CA 51'c- - CA(`J10,64(i-1 PLACE OF DEATH: G /eA)6 +Ai is lit se,L' — IOC ov- k{ L Cle,i5 - l(s) ✓y, /zgo / ESTIMATED WEIGHT OF REMAINS & CONTAINER /75- /b5 7ZQZ 4C" 5 l z PLACED IN HOLD: /D PLACED IN REFRIGERATION: DATE OF CREMATION: //" ?5 -20Z �� TIME STARTED: 7/,� TIME COMPLETED: PLACED IN RETORT: I /' MOVED: C) RETORT# IN WHICH REMAINS WERE CREMATED: PO er '�. . 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. r. New York State N Department of State YOR1( 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 Authorization for Cremation and Disposition This Authorization Form must be completed and signed prior to delivery of remains for cremation. It this form is not properly completed or executed,the crematory may reject delivery ofof the human remains. Date: 11/18/2023 Case Number: / 37 (for crematory use only) Crematory Name: Pine View Crematory Address: 21 Quaker Rd., Queensbury, NY 12804 Phone: '::).-t s?, . f Zo j - o� 19 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 crerriatien, the crematory will take reasonable efforts to remove all of the remains and other material from the cremation chamber, but som_: minimal dust and residue will likely be left behind. The crematory will separate incidental and foreign material from the remains arid tl,e incidental and foreign material, including dental work and implants, will be disposed of as permitted by law. The cremated remains,',All 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 Nan e of Dec+;::ise is Emma E.Nelson Marital Status: Never Married Last Known A !:In ss: 30 Chestnut St., South Glens Falls,NY 12803 Pl ne of DeaL. I. :nicipality: Glens Falls State: NY Gender: F X Age: 27 DOB: 05/16/1996 Date of Death: 11 17 2023 175 / / Estimated Weight: Cfl :n' Or: Ttt _CONTAINER The nator. ma:, only open the container holding the un-cremated human remains in limited circumstances, such as to confirm the ide r. ., of thetl-k used or to ensure that no material is enclosed which might injure employees or damage the crematory property. If human remain.,,a. : delivered in a container which is not suitable for cremation such as ceremonial or rental casket, the crematory will re' li at t ; r: rains be moved into a suitable container before it accepts the remains. The opening of a container or the transfer or renuval of remair:.,will be conducted before a witness and will be done in privacy, with dignity and respect. ='n!PTIOij OF CONTAINER IN WHICH REMAINS ARE BEING DELIVERED _,r ppiier: Buffalo Casket Material: Cardboard/OSB C` 'I% ^ .TAINERIURN (J� E cc 3r-;allowing) I;`..''Je I ave provided with an urn to be used as a container for the (Name of Crematory) cram 'Led remains. I/We understand that if the urn is too small to hold the entire cremated remains, an additional rigid c ,te.ler may be used for delivery. Description of urn: ii •;:: we 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) container for delivery. D. o ,3-t _:6/23) Page 1 of 3 M Authorization for Cremation and Disposition PERSON IN CONTROL OF DISPOSITION (Person(s)in control of disposition, initial ONE of the following) I amivVe are the designated agent of the deceased designated in a will or written instrument executed pursuant to Public Health Law Section 4201. Vv IJJe nave no knowledge that the deceased executed a written instrument pursuant to Public Heath Law Section 4201 or a c\.., will containing directions for the disposition of his or her remains and I/we are the person(s) having priority under Public Heath 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 !,er: Description: 2. The surviving spouse; 13 . The surviving domestic partner; Any surviving child eighteen years of age or older; 4. A surviving parent; . . A surviving sibling eighteen years of age or older; G. 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; 0. A duly appointed fiduciary of the estate; A close friend or relative who has executed a written statement pursuant to Public Heath Law Section 4201(7); • A chief fiscal officer of a county or a public administrator appointed pursuant to the Surrogate's Court Procedure Act; %a. 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 n..mbers 3, fe and 7 above, by signing, the person(s) signing this Authorization Form represent that they are signing on behalf of a ma;: r,!y of the members of this class of persons who are reasonably available. (1 i' ,/ 3OT,',. ;3°c following) I. i[ereby affirm that the body of the deceased does not contain a battery, battery pack, power cell, radioactive implant, ,U • „ •!ioactive device and that any such materials were removed prior to the execution of this Authorization Form. Failure remove these items prior to cremation may result in harm to the crematory and crematory personnel. IfA/e :affirm that instructions have been given to David Alexander (Funeral Director Name) C)<:rding the removal of any personal property or other thing of value which any person signing below or any family nn o)er 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 +r left in the container or with the remains will be destroyed by the cremation process and cannot be retrieved after cremation. In ',°Ti " : I .iereby 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 -ct name and address of such alternate crematory. Name of deceased: Emma E.Nelson DOS-1898-f ( 06/23) Page 2 of 3 . Authori __ztion for Cremation and Disposition FINAL DISPOSITION The final rest, ,; place for the cremated remains of the deceased is © Placemc in a grave, crypt, or niche at Ei (cemetery name) fnatterin ,s permitted by law C. ,r Return to family (description) TIn• • :T!ni,rized to receive the cremated remains of the deceased from the crematory is: (Address) (Phone) If:. authorize the funeral director executing this Authorization Form, whose name appears on page 3 of this form, to receive cr : .Id a representative of his or her funeral firm to receive the cremated remains on my/our behalf. If 1 r-. Lhe person named above does not take possession of the cremated remains, Pine View Crematory is authorized to give possession of (Crematory Name) the c. ,u;ati. mains to Alexander Baker Funeral Home (Funeral Home Name) in r • nn GI delivery by the United States Postal Service, as permitted by its regulations and procedures. (1 f? . Mg) g) , .\\...) understand that if the remains are not claimed within 120 days of cremation, Pine View Crematory (Name of Crematory) dispose of the remains in an irretrievable manner, as permitted by law. T` the n>n 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) am! 1 -..igne. the funeral director as witness to its execution. lr. 'c r< r:ed a completed copy of this Authorization Form. li. 1: . person(s)in control of disposition,who by signing this Authorization Form,attest(s)to the accuracy and cc ill tene : of the information contained in this Authorization Form and hereby authorize(s)to cremate the remains of the dc" :c ;r ird. Si,,,,, tf,i<, " 8th day of November 23 ,, Jacqueline F. Nelson ,, ,,cJ� ------- Sig Owe 12 Thomson St., Warren urg, ew York 12885 A, Signature A.:: 7' Signature A,: V: S: David Alexander (F '.;,rod Name) ( rector Signature 10034 (Y Name of deceased: Emma E. Nelson D •PO-"t nw. 06/23) Page 3 of 3