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Fausner, John T Pine View Cemetery & Crematorium Quaker Road Queensbury, NY 12804 (518) 745-4477 or (518) 745-4476 FUNERAL HOME: 3aL) EZ- RETURN TIME: f15FF DATE & TIME REMAINS ARRIVED AT CREMATORY: IZ/�5 I Z 3 1Z NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS: fP,INN MiLc, _ NAME: TO WO T fC' CASE # ICZ� TYPE OF CONTAINER: f'IICC%'f}u�' ;+1 _re) tj'I k( /G Atli PLACE OF DEATH: tit E as Fri L z' [� ESTIMATED WEIGHT OF REMAINS & CONTAINER 7 s0 its- PLACED IN HOLD: !2:3t.f1 PLACED IN REFRIGERATION: DATE OF CREMATION: ILI70 Ill TIME STARTED: TIME COMPLETED: 101) flin PLACED IN RETORT: :(20 411 MOVED: `'s©' i yit RETORT # IN WHICH REMAINS WERE CREMATED: U- PR14= 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 fr-INY RK Department of State DIVISION OF CEMETERIES One Commerce Plaze STATE Cemeteries 99 Washington Avenue Albany,NY 12231-0001 Telephone:(518)474 6226 httpsfldos.ny.gov Authorization for Cremation and Disposition This Authorization Form must be completed and signed prior to delivery of remains for cremation. If s form le not properly completed or executed,the crematory may reject delivery of the human ramalns. 12/17/23 1Czl Date: Case Number; i (for crematory use only) pine View Crematory Crematory Name: Quaker Road,Queensbury,NY 12804 518-761-8279 Address: Phone: CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS. Cremation is carries out by placing the remains of the deceased and the container holding the remains into a cremation chamber where they are subjected b 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 crematior,the crematory oil 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 until no single fragment is recognizable as skeletal tissue. IDENTIFICATION OF DECEASED John T. Fausner Widowed Name of Deceased Marital Status: 15 Swears Rd.,Stony Creek, NY 12878 Last Known Address: NY Place of Death:MuniCipaliy: iU State: El ©c ge;91 12/19/31 12/16/23 h� Gender: M X A DOB: Date of Death: Estimated Weight 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 night 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 WHICH REMAINS ARE BEING DELIVERED McDonald Container Cardboard Manufacturer or supplier: Material: CREMATION CONTAINER/URN (initial ONE of the fallowing) Pine View Crematory I/We have provided with an urn to be used as a container for the (Nana of Crematory) cremated remains.I/We understand that if the urn is too smal to hold the entire cremated remains,an additional rigid container may be used for delivery.Description of urn: -OR- lme have not provided an urn to be used as a container for the cremated remains,and understand that Pine View Crematory wdl place the cremated remains in (Nerve of Crematory) a rigid container for delivery. DOS-1898-f(Rev.06/23) Page 1 of 3 i•d eZZ:80£Z 8 L oea ,t • Authorization for Cremation and Disposition PERSON IN CONTNOL OF DISPOSITION (Person(s)In contr*of disposition,initial ONE of the following) I amN4e are the designated agent of the deceased designated in a will or written instrument executed pursuant to Public Health Law Section 4201. -OR- ''.- -...._i/We have no knowledge that the deceased executed a written instrument pursuant to Pubic Health Law Section 4201 or a ,,,,..;a;..,.,g 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: Number:? Description:nepttew 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 guar tan; 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 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 of the members of this class of persons who are reasonably available. (Initial BOTH of the following) INYe het+eby affirm that the body of the deceased does not contain a battery,battery pack,power cell,radioactive implant, or raarqsicave device and that any such materials were removed prior to the execution of this Authorization Form. Failure to rembve these items prior to cremation may result in harm to the crematory and crematory personnel. �i '�_I/We affirm that instructions have been given to Patricia Miller ' (Funeral O cE0rNam. 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. Pine View Crematory (CrernatoryName) is not sponsible for the removal of personal items from the container or from the remains of the deceased. Personal Items 1 R in the container or with the remains will be destroyed by the cremation process and cannot be retrieved after c. Non. (Initial OPTIONAL) Me y authorize the named funeral director to provide for delivery to and cremation by an alternate c ,if deemed necessary in the opinion of the funeral director,and to amend this form to provide the come name and address of such alternate crematory. • John T Fausner Name of deceased: DOS-1898-f(Rev.06123) Page 2 of 3 Z'd eZZ:90£Z 9 L oea t Authorization for Cremation and Disposition FINAL.DISPOSITION The final resting place for the cremated remains of the deceased is ElPlacement in a grave,crypt,or niche at Knowlhurst Cemetery ElScattering as permitted by law (cemetery name) ©Other I (desolation) The person authorized to receive the cremated remains of the deceased from the crematory is: (Herne) I (Address) (Phone) t 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. Pine View Crean tory is authorized to give possession of Brewer Funeral i-I�-leome, Inc.) the cremated remauls to (Fume/Homo Name) in person or via delivery by the United States Postal Service,as permitted by its regulations and procedures. ()loll the following) I/We i*erstand that if the remains are not claimed within 120 days of cremation, ,.-.z.V:. - , Crematory I (Name ofCremetory) may d i pose of the remains in an irretrievable manner,as permitted by law. I This AuthorizationiForm was provided by Patricia Miller was executed at Brewer Funeral Hm (Feneiat /0lrer#D.Nema) e, Inc. (Fimaaf Nana Nam p 24 Church St., Lace Luzeme,NY 12846 1 (Funeral Nome Address) and is signed by the funeral director as witness to its execution. I/We have received Ia completed copy of this Authorization Form. I1We am/are the ' on(s)in control of disposition,who by signing this Authorization Form,attest(s)to the accuracy and completeness of a information contained in this Authorization Form and hereby authorizes)to cremate the remains of the deceased. Signed this 17 day of December ,21123 Ken Keenan1 c-- --..---- -5...__> Typed a Printed Name . Signature 14 Sea Cliff Ave., Ner Place,NY 11764 Address Typed or Printed Name Signature • Address Typed ar Printed Naze Signature Address c;(sue.e.....1 WITNESS: , Patricia Miller (rimers/Chador Toped or Prided Name) Nowa,D'ernr ) 12465 (Registration Number) , John T. Fausner Name of deceased: DOS-1898-f(Rev.06/23) Page 3 of 3 £.d e£Z:80£Z Si.oeC