Eggleston, Lynn Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: (I Me, /� p RETURN TIME:
DATE S TIME REMAINS ARRIVED AT CREMATORY:
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
I (
045
NAME: LIdp)Emle�li. ,I 1 CASE 71
TYPEOFCONTAINER: ab fA 'A
PLACE OF DEATH: 416 )EJ � ;4r 4 G - Id � JJ�
ESTIMATED WEIGHT OF REMAINS 6 CONTAIHERJI� �6 S
PLACED IN HOLD:
PLACED IN REFRIGERATION: .9 f
DATE OF CREMATION: 11 -6 "IBZ
TIMESTARTED: I )e� TIME COMPLETED:
PLACED IN RETORT: �� MOVED: VT'-�M
RETORT # IN WHICH REMAINS WERE CREMATED: Pa')OTf DM?Afj
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE:THE CREMATION LOG SMALL RE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
L�Z v�roaK Division of preI51 CEMETERIES
prm ,
Cemeteries 99Wo °otn,N ,,, a ,runt EAs4MMrA
Authorization for Cremation and Disposition
FAR ANhorZa Form soft be adn~end signed pNor m deal of remama W crematlon.
opffift zo chamber. 71�—
clemalary Nama. Pire view clenelary
21 QmwM Rind,Ouenebury, NY 12801 PMm, (518) 7ASM77
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cmmaam is nr Wby placing be rwn Ice of the demaaM And Me for it holding in$mmm I=a annual Chamber where
teyamsabjecm ito nse MmaMname. The MORRIS MMGMIl loclnraX and mnsumawnylhmg except bon and mNl.
w icharean ScotwIRbskRahncremMon.
Following Cremation, me aemetonc^Il toe reasonable enorbto mn M au Of AM war and toner mamnal o- m dn Me uea40n
chamber butmme misted dodged ressue will study toy left behind oTne nemamrY wtll wwral9 mmdentel arA(weRn meleNl tam
me remains and the incidental and Mi mml l All be disposed of as regaee l by Warr. The uemmed remama its W mechanlally
pulyrimimo smau giem and passed imoa designated consumer ovum. Cmma%dremainsgonemnyempule duntllm
angle togmsm Is rmognmMs as 3"lenl Besas.
OPEN M OF THE CONTAINER
The cnmatary may Only open the mother Fashion lee um mated bunch remainsm limited commercial ml Such as confirm the
party 0Metlm sM or an ensure that not matenal 'u endosed Mich might Same employees or damage Re final propeM If
human remains ere dxlwrM In a mnMlrrar whim b not rumble air cr "m such as commie al or rent cal the
tab Owill require MAm smiled be moved Into a suitable conallner lesion Xacup4 We remam. The oaenin90M
mmeule rNe EanMwremwal of remeira'nYllMmrquded belaree WbafsserA VAA t9 tlmern privacy, wile dignity and reseed.
OENTIFMATION OF DECEASED
Name M Dx sed Lynn Eggleston MBMN Stdus: Dmrm
leg Kman Address: 4 Genwmd street Albany NY IM03
Place of Rat: 4 Obnal SOeet Albany, NY 12M1
sex: 13M 0E Age. 71 we 12/10/1948 R ors m:010312020 Esrmawmv m: /!S�
Rconcran of msl mmwin wtvchM MWWII be danswmd.
Carsibout Box w/Wooden Base
PERSON IN CONTROL OF MMSITIM
pdwEw yrn ronOW ddf m. mandet ONE anto btluNnM
eml are tM designated agent M to edmaasd tlwgMt In afall an n InsWmem executed pursuant A,Public
Health Lew SMion 4201.
-OR
}JB/� me have no crowha eMat the demand mommed a Mtn dmWmem pursuant b Public HoWth Law Senn 4201 ore
Ads mntmng dlrediorn he to disposition W he or Mr remains and Wn en m Wmr (s)m ing pnoMy under Pulax HMM Lear
Section 4201 and have Me fight to autom ,rrsmal of m remains M the M aW Mydi mlalloAl b the de UOd Is am
fAw
Lynn Eggleston
Ruff EPA—
WS1S9SryRev. 0U2a Pqe 1 Of 3
_ ♦ I
Authoriution for Cremation and Disposition
Therax Mon Me set Ni
Number.3 Doormoon: Carol Egpbsmn Men)
1. A Mason moignaleamwaing WnWm to punik HNM Law Session 4201(3h
z. TM auravmp spouse.
U. no surviving dome tend partner,
3. Any Curvmng caw sigma eased of ape or older;
a. AsurvlNl parent
6. A waiving aiming optimum"am of ago or olan'.
S. A Merrily aphoi mad guardian
3. Anylghman"am M aaa or mmlo]madare m es
tate R dNB e and iLan in relBtionane me awsee mh dIsraeliin ;
e. A uryappnmme rmuue whoh the eamfe'.
S. Atlomtipnamrer of a wnonasamabeans ni abM1mempunoam to anttoM Health Less ore 4301p},
10. AyOther move
por,wof a sound on hadei of Me mMar andwred pu Necume Sunosaa'surniurt proAOWBAq:
IN. Layo ion Ronvnorex9ne on tennlMUe aomaaetl enewnn IN exeaNN avaran&abmem punum)m puMm Realm
Lay sealpnaangx).
(.LA�NffAA�u THREE of me roPcwmm
'1(�INh la'Bnv amrm son Me eWy Mma eemaaeE eom notccnmmaeatlen, ]srlsrYwck. mpwagll, nMm wimwaM
or mo icamme eevlce also Met any sum mafenal5were removes mayor Missouri of Mie Auf abn Form. Fellunbmnms
Nam nears prior m cnmam n may mutt in harm bMe cmmaory and camel penonnel.
WJe aMnn MalinaWcrore have ncen Coen to Rolland G. Men
Missing the removal of any parwnal proseM or other thing of value,which my pry n&gnirg blow or any hour member MM
eecri wsim mar mire Vtrw Crtmffiry
n nanapanaide fcr Ma remwel of penmel ibmahom Me Wmeinp d Irom me mmaimmme aemsaea. maroons lama bn In Ma
mMalnerttwM the remams will be,aesboyaa 4 No ommuon propose and mnnotts,removed sflaaremsnon.
DOkMMahere aahodm pine Ml wCMMal
nwwm m cnarate Na remains a No a acrosW.
(Arced OrnoxaL)
thw nsnhy atmorlm Na named permit mrctlor m provide for dNaxy m and onmauon by in alternate
sal XMemed necessary In Me opinion of blue furenI director,and mamend trip lam to provide Me COMO Man&and
dsa ma a such ammo mmamry.
FINAL DISPOSffION
The qxn aWMri to receive Me cremated imam of par dexeeed Nam Me Crynalory Is:
Nam: Compamonale Funeral Care
Address: aM Maps,A" Saramge Spnrge Nv 10856 pis. (biN 5Ed'i8M
no prtmated remains of conceal tell CB dY Was Mlaus
Realm To Famih
It M any mach No poison named above of net same pmmmon of Ms tlamtlm imam,
P'"U Cremamry Is aWMxM he gw gNM of
tlEmmainb xa+ Cmpa"i FurealCan, Int by bol'wry
In parson or by ngebred ma , �uwurmxewl Lyon Eggb n
005l1 f(mv. NOW) o>.� Mail
Authoriution for Cremation and Disposition
r�Ma kNmwrq)
J3.4r—INJa trdmisbN Met 6"remains are Its ommNvnpin uo departmental
P'agY Crimabry
avnc�wN naYtllgme MMBrMMire In
an nretrevetllB manna[such as by eCBlbnnp.
CREMLT GX CMTANERNRX
(tar if CAE offt hWnstat
An um to Ea ward m a cartel he Me uameMd minim mans again WrNUM som
am Is described as bllows'.
IM1Na untler d tat If Me um 1s too email to MM Ms anon v Wl m.an WO al rpk central may N used W MlMry
ow-
�MumMMyelplMm¢d. IMp uMerebrq Mat lino unls WrCMeNIXOtlRrwiw pmwtletl i
Puna"ne Crematory will Place Me normal remains In
mm.womvey
a idea temorrery mnMinN M delivery.
T11ia Auµv4atbn Form win provided!py ROMN G. NOp was executed at
CmWeubmte FuneN Care, Inc
103 Maple Aw. Garataga Spins NY 10W
I
and w SQn by to homes d'xOtlOr as mrsom to IN annual�
IANe nave leq' a wmlMal copy of Wa AUM atl Farm.
The pomoMe)Itlandrad G him in Me purwnbt In conWl of dlspmltlon,Moit'signing sells ANM1wze on Form,atbeNe)
to Me accuracy and complains of µe IMormentn conhlmd In MY AUNadmakin Form and aid with)to bragwnp.
Slpmd Mb OM day of Jum ,t030
Wall ENImtn
111 1-1
a Glwm<aJ gtreaL Army, NY IZ
mail
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