Benson, Gerald Gregory . Y LF
x �
Town of Queensbury
Pine View Cemetery and Crematorium
Quaker Road, Queensbury, NY 12804
(518) 745-4476 or (518) 745-4477
Funeral Director ��fy
Name Case No. 52,3
Date of Cremation
Time Cremation Started
Time Cremation Completed 3` pn
fECGOD C
Type of Container a-a boa, r5� �S
YP .
Remarks
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NYS Department of State
_ thorization for Cremation and Disposition 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: IVoV:0,bzr (p 764 Number: 5 23
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 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 cremation,the crematory will take reasonable efforts.to remove all of the remains and other material from
the cremation chamber, but some minimal dust anu residzi �jfiii`liK�ly Eh; @;ff behir& The crematory will separate
incidental and foreign material from the remains and the incidental and foreign material will be disposed of as
required by law. The cremated remains will be mechanically 1 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 OF 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 might injure employees or
damage crematory property. If human remains are delivered in a container which is not suitable for cremation
such as a 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.
IDENTIFICATION OF DECEASED
Name of Deceased:
Marital Status:
Last Known Address: / G/j ///T, S as"76 V
Place of Death: ? p �ypJ G �✓� Cam/,.
Sex: yvM ❑F Age: (o DOB: Date of Death: 7- pip Estimated Weight•
Description of caskeVeontainer in which remains will be delivered:
ALTERNATIVE CREMATION TRAY: CUSTOM AIR TRAY,WOOD BOTTOM,CARDBOARb TOP, NO INTERIOR
PERSON IN CONTROL OF DISPOSITION
(Person(s)in control of disposition, initial ONE of the following)
I am/We are the designated agent of the deceased designated in a will or written instrument executed
pursuant to Public Health Law section 4201.
gyp,-OR-
1 a _ I/We 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-189844 (Rev.01/10) Name of Deceased
Page 1 of 3
I-arAV are the br_son(s) having priority under Public Health Law section 4201 and have the right to authorize
cremation of the iemains of the-deceased. My/Our relationship to the deceased is as follows:
(/nse►f from the Us6Uelow)
Number_ Description:
1:A=person designated in writing pursuant to Public Health Law section 4201(3);
2 Tfie surviyFirigspouse;
2a.The survtving_.domestic partner;
3.Any surviving child eighteen years of age or older;
4.A surviving parent;
S.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; .
,A.A appointed fiduciary of the estate;
9.&close friend-or relative who has executed a written statement pursuant to Public Health Law.§4201,(7);
A:chief fecal officerofra countf or a'public'adriiinistr'atorappointed p! rst!3nf'to the�.urregafea.Co�rt''""
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§4201(7).
(In"i 1 ALL THREE of the following)
IM. e hereby affirm that the body of the deceased.does not contain a battery, battery pack, power cell,
radi64ctiv%t� im4,p1ant or radioactive device and that any such materials were removed prior to the execution of this
Autf orizat idnrForm. Failure to remove these items prior to cremation may result:in harm to the crematory and
crematory personnel
I/We hereby affirm that instructions have been given to(funeraldirectorname) James C. Aubin
regarding the removal of any personal property or other thing of value which any person signing below or any family
member pf-the deceased wishes to preserve. (crematoryname) Pine View CrematorY.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.
,[We.hereby authorize(crematoryname) Pine View .Crematory,Queensbury,NY to cremate the
` emaiioftledec"ea§ed.
' J�IN��DI�PO-SITIOtR!_"' . :'._,-.... ._.-• ... �� .� _._..... .._. .._-..._.._._._ �_._._. __ --" x - - --- - _: -: "
The person authorized to receive the cremated remains of the deceased from the crematory is:
Name: 0,6;ff,
Address: Al rL 5, f, ��GL lltxew,t j17- p 6 7y3 Phone:
The,cremated remains of deceased will be disposed of as follows:
/-j - �� s 1
_ :_Jf for:any_reason the,person named above does not take posses on of the cremated remains,
;(creniatoryname) Pine View Crematory,Queensbury,NY is authorized to give possession of the remains to
(flirieiallhomename)-•.:.Duxfee Funeral Home..,Fair Hayen,VT by delivery in person or by registered mail.
DOS 1898 f 1 (Rev.01/10) Name of Deceased Page 2 of 3
F
{Initial,the follorwhi)
I%We;undemtan_cl that if the remains are not_claimed within 120 days of cremation,
(crematorynarne) may dispose of the remains-in an irretrievable manner;
such as�tyacattenng.
h
ACRE AMOWCONTAINERMRN
(Ini ip 1�0NEaoftt%§'following)
An um to:be used as-a container for the cremated remains has been purchased from
and is described as-follows:
Ifte understand that if the urn is too small to hold the,,entire cremated remains., an additional rigid container may be
used.for delivery.
OR;
An.um;:has.not yet been purchased. I/We understand that if no urn is purchased or otherwise provided
(cremAl—,name)' Pine view Crematory,Queensbury,NY will place the cremated remains in a�rigid temporary_
-coritai e�'for delivery
This Authorization Form was provided by.(funeral director name) James C. Aubin
was,executed`at4(funeral home name) Durfee Funeral Horde_.
(funeral h6me'addm#) .-119 No. Main St::.P•0.Sox 86;Fair Hauer,VT 05 743andAs signed by the funeral director
as witness to°its:execution.
I/We have received a completed copy of this Authorization Form.
The-persdn(s),identifred below is/are the persons)in control of-disposiition,.who by signing this
Authoo "ri Form;attests) o,the accuracy and.completeness of the information contained-in this
Authonzation`Form:and authorize(s)the foregoing.
Signed this �Z-7 day of -L�V�2 � 20 10
i_C�S(a 3e-n SO r M
Typed or.Printed Name gignature
Address
,- 'jTPW Signature
T
.r-
Typed or Printed Name signature
Address
WITNESS: r
James C. Aubin
Funeral Director Typed or,Printed Name Funera rector signature
022-0001030
Registration Numb&
C
DOS-1898-f-I (Rev.01110) Name of Deceased Page 3 of 3