Case, Mary B Town of Queensbury
Pine View Cemetery and Crematorium-
Quaker Road, Queensbury, NY 12804
(518) 745-4476 or (518)745-4477
Funeral Director ?or cop
Name r.r!, Case_. Case No. � 15
Date of Cremation 0ve bcr 11 , 701 b
Time Cremation Started 11 ,00 Ah
Time Cremation Completed 1: 36
Type of Container pJLOMIJ '[O K 0 C
Remarks
y`A
Authofi2 ation for Cremation and Disposition NYS Department of State
- p Division of Cemeteries
One Commerce Plaza,99 Washington Avenue
Albany,NY 12231
(518)474-6226
www.dos.state.ny.us
This Authorization Form must be completed and signed prior to delivery of remains for cremation.
Date: I I\kutrv,6r- (U , ZQ 10 Number: 51 C, -
I
Crematory Name: PINE VIEW CREMATORY,
Address: , 21 QUAKER ROAD, QUEENSBURY, NEW YORK 12804 Phone: 518-745-4477
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 ,hamber where they are subjected to intense heat and flame. The heat and flame will incinerate and
consume 3verything except bone and metal,which are all that will be left after cremation.
Following rernation,th&.crematory.:ill take reasonable efforts to rer-rave all of the remains and other material from
the crema1nd
on chamber, but some minimal dust and residue will'likeily be left behind.The crematory will separate
incidental foreign material from the remains and the incidental and foreign material will be disposed of as
required byl law.The cremated remains will be mechanically pulverized into small pieces and placed into a
designated container or um. Cremated remains generally are pulverized until no single fragment is
recognizable as skeletal tissue.
OPENING t7�F CONTAINER
The crematory may only open the container holding the un-cremated human remains in limited circumstances, such
as to Conn the identity of the deceased or to ensure that no material is enclosed which might injure employees or
damage ciclremonial
atory property. If human remains are delivered in a container which is not suitable for cremation
such as a 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 b�fore a witness and will be done in privacy,with dignity and respect.
IDENTIFICATION OF DECEASED
Name of D4eased: r��-�_ y� /�
Marital Status:�/jGil/�iG�C�
Last Known Address: / 2 Si & v p S-7
Place of Delh: 97-
- t1TDc�'ZG
Sex: ❑M WF Age: pOR; -4 7- /3- lqc�a' Date of Death: Estimated Weight: /1p
Description of casket/container in which remains will be delivered:
ALTERNATIVE CREMATION TRAY: CUSTOM AIR TRAY,WOOD BOTTOM,CARDBOARD TOP, NO INTERIOR
PERSON IN CONTROL OF DISPOSITION
(Person(s)in cpntrol of disposition, initial ONE of the following)
I arit We are the designated agent of the deceased designated in a will or written instrument executed
pursuant to Public Health Law section 4201.
-OR- I
Me 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 (Continued next page)
DOS-1898 f I (ReV.01/10) Name ofDecea Page 1 of 3
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f
I arnJ 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:
(Insert from the li t below)
Number:/ Description: Aer��
1.A person designated in writing pursuant to Public Health Law section 4201(3); ,
2.The surviving spouse;
2a.The surviving domestic partner;
3.Any survi ling child eighteen years of age or older;
4.A survivir g parent;
5.A survivir g 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 duty appointed fiduciary of the estate;
9.A close friend or relative who has executed a written statement pursuant to Public Health Law§4201(7);
10.A chief fscal officer of a county or a public administrator appointed pursuant to the Surrogate's Court
Procedure Act;
10a.Any o er person who is acting on behalf of the deceased and who has executed a written statement
pursuant o Public Health Law§4201(7).
(Initial ALL THRE of the following)
I/We 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 Fo rm. Failure to remove these items prior to cremation may result in harm to the crematory and
crematory personnel.
IMe hereby affirm that instructions have been given to(funeral director name) .Tames C. Aubin
regarding the rer ioval of any personal property or other thing of value which any person signing below or any family
member of the d ased wishes to preserve. (crematoryname) Pine View Cremator)r.Queensbury NY is not
responsible for 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
I/We hereby authorize(crematory name) Pine View Crematory,Queensbury,NY to cremate the
remains of the deceased.
i •
FINAL DISPOSITION, •+
The person authorized to receive the cremated remains of the deceased from the crematory is:
Name:
r
Addre f/I� /lJe. R967(- 37, e5-7113 Phone: jD�,M— L*P ,
The cremated remains of deceased will be disposed of as follows:
If for any reason he person named abo a does not take possession of the cremated remains,
(crematoryname) P'ne View Crematory,Queensbury,NY is authorized to give possession of the remains to
(funeral home name)_ Durfee Funeral Home,Fair I-iaven,VT by delivery in person or by registered mail.
DOS-18Wf-! (Rev.01 10) Name of Dec;p4d Page 2 of 3
i
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e following)
IM9 unde and that if the remains are not claimed within 120 days of cremation,
(crematory name) .G�G� may dispose of the remains in an irretrievable manner,
such as by scatte g.
CREMATION CONTAINERIURN
(Initial ONE of the following)
An um to be used as a container for the cremated remains has been purchased from
and is described as follows:
IMe understand that if the um is too small to hold the entire cremated remains,an additional rigid container may be
used for deli%ery.
-OR^ '
W An um has not yet been purchased. I/We understand that if no urn is purchased or otherwise provided
(crematory name) Crematory,Queensbury,NY will place the cremated remains in a rigid temporary
container for delivery.
This Authorization Form was provided by(funeral director name) James C. Aubin
was execute at(funeral home name) Durfee Funeral Home
(funeral homes ) 119 No. Main St ,P.O.Box 86,Fair Haven,VT 05743and is signed by the funeral director
as witness to its execution.
Me have received a completed copy of this Authorization Form.
The person()identified below islare the person(s)in control of disposition,who by signing this
Authorization Form,attest(s)to the accuracy and completeness of the information contained in this
Authorization Form and authorize(s)the foregoing.
'I; A day of ��� 20 1b
ed this
I
Typed or Print ame r nature
aw
s�-
Address
Typed or Printed Ilame Signature
Address
Typed or Printed Name Signature
Address
WITNESS:
James C, Aubin @ s
Funeral Director Typed or Printed Name Funeral Di gnature
022-QOQif1030
Registration Numf er
DOS-18984-I (Re4 01110) Name of DecjAd Page 3 of 3
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