Disisto, Donna Pine View Cemetery & Crematorium
Quaker Road
Queensburyl NY 12804
(518{ 745-4477 or (518) 745.4476
FUNERAL HOME: A.EYp RETURN TIME:
DATE S TIME REMAINS ARRIVED AT CREMATORY: _ -71M__W_7zy
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
�N12 QLECARIDf9
NAME: PIEEN ' (71b4T-t0 CASE R 871r
TYPE OF CONTAINER: f/eMA /[I1 111 Izo6 l
PLACE OF DEATH: _ Dl(j h:y Lf { �O'IRi6R {jar
ESTIMATED WEIGHT OF REMAINS S CONTAINER
PLACED IN HOLD: /qy
PLACED IN REFRIGERATION:
DATE OF CREMATION: 7/4 {jp
TIME STARTED: i&-O AYI TIME COMPLETED: Y�MIGI'{
PLACED IN RETORT: _ I 7mpn MOVED: �J'T4I'tI',I B'yOryi
RETORTS IN WHICH REMAINS WERE CREMATED: AfLg(1:'• tAK
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 4a HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE THE CREMATION LOG SHALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
NIIYWkSPm
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NEWIDRK Division of DIVISION OF CEMETERIES
SraIFOF ne Commerte bills°' °" °"'TY Cemeteries li mmAweoe
Y12131aurn
Teen o e' Islal474-1
Authorization for Cremation and Disposition
This AaOoadval Form must be completed and signed prbrto delivery ar remains for cremation.
Date: 07/11=0 Number. 87r
Chancery No" Pine Yew Cremal
Andrets, 21 Quaker Rd., Oumnabury NY 128M Phone: f ('
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation is caned out by placing me remains W grotlxeaaed and me wnbiown nabirq rM somehow arch a cremation chamber Men
In"arc subpded to intense Ms1 and Mime. no hM and flame will Incinerate end roneuma emotional except bone and Miami
W ich an all Mal sell I be left after chamaEOn.
Following[remises,the Uematory will kite reasonabb a oft IO remove all adMe remains and prom rratedal from the cremation
Uamber, outcome minimal dual and residue will likely be left behind. The VemBtorywsl sumarms invder l and design madenal ham
Me remains and Me Incidental and foreign material will ba disposed of as haguiM Wayne me arereaW remema wiR ee meManiwly
pWnnaM Inch small pieces and placedinto a N Qnaled comiircere um. Cnmekdm ire SanwellyampuearkMuMInO
single fragment Is essential as import t ua.
OPENING OF LINE CONTAINER
The IXemaery may only open the conewpor holding me un<remand human remains In limited countenances,such as to cannot the
Hardly W Me decried or to ensure that no malarial Is massed which might Injure employees or damage me crematory pmpeRp N
human Remains am delivered In a container which is net suitable for emmNon such as symbol or mdal ueket.Me
maery,will repulre Mae the remains W moved Into a suitable container seems it accepts Me remains. no toward of
contaurer or Me tnni Or removal of remains will he composed [sere a witneam and and be done in pinery, wimp diibm amp nee
IDENTIFICATION OF DECWE0
Name convenience Dona Di916to Madkl Sties: NBVaf Married
Lem Nnem Adores 3753 Main St, Apt 5, Wenensbul NY 12885
Here of Comity Deceased's Residence, 3753 Main SL, Wapereburg, NY 12885
Sex: Die 19F Age'. 49 Di 11/OB/1970 Only of M. 07/0Bf2020 Fsamatadwagm 135
Description Mcadmider ttirer In MMA remains will be Salvador
Flounce deluxe cardboard
PERSON IN CO ITROLOFD POSrt ION
lPetddi In=1m of mospeffel Prefix PYE of me Aerosol
I amAYe one Medesignated agent of Me downward deaigna In a MII or wrTen instrument Opposed arewint to Public
Health taw season 4201.
OR.
Ism havenoknowledgeeetmedecriedemc a wMten InstrumentpursuamaPuair Nemm law Scopesa2G1 are
n wnbming directions mr tee daposulon once orner mmtins amp 1Me ere me pmson(S)nav ng primly under Public Hm* Law
Eectoral and have the right o amhorime cremation arms remains oftne decried MylOur maeenanlp Ia ma deceased ism
Wilson:
Donna Disisto
O 189Sl(Rev. 04l Page 1 ov
Authorization for Cremation and Disposition
reclean ddm me nvcerow)
Nudmer: 4 oescnpYon:Fath
1. Abortion EesgnetW In wri ieg Wrstianito Pubf Mail law Section 0201(3);
2.
. TThhedrrvvwvi� domestic canner;
5. My urvwhrg child eighteen years so age or door:
a. Aauniex pareml
5. A surviving sibling eighteen"am of a"Or Over
S. A lawfully a nfar governor:
T. My perampt eighteen years of age or older dead W share in the estate and who iLare closest in romenbMlp to the reveal
a. A duly equipment 0duaary of the estate;
S. A dose bland or relative who has executed a written statement fursuam W Public Head Lew SeGIon4201(T):
10. Achor h6al oMttr Of a Cony or a public adml nistnWr appointed pursuant to the Sunwate's Court Pmpmre Ad:
Ii My Other who is aping On card If of the dewawtl and who has executed a written stelemeM punuaht to Public Health
Law eastern 4201 Pets
g a(dl ALL THREE or Me NWwing)
IMWh tmMry arm tat the Cary of the demands does not contain a battery,battery pack, power cell, ndiwNve Implant
orrMWadie device and Mal any such mabsak ease remMM prior to the syndrome of this AWhoz"m Form. Failure to nacre
Mines Items prim to cnaaron May nwn in harm to they cmmMM and crematory Personnel.
II arum that mainstream have been given John Alexander
l�nr�
regarding the removal clan penorol pmpMy or Other Ming of value which any Person signing balow or any kindly member M the
Mohamed wishes to preserve. Pine Vier Crematory
a net dispersion for Me removal of Personal items hen the corminer oinnm the remains Of the deceased. Personal forms N In Me
�y�y w�.=lnen or whh Me Remains win ba Mstroyed by the cremation pmcaas and cannot be nlnwed star cremation.
Vra`—MahenbyauMorim Pine Vim Crematory
to mash the maim M Me awwed.
Io�OPTIOIJAL)
IHn hanby authorize the named funeral director W pmrieJor delivery to and cMM$Von by an alternate
nmmory,repassed trademark In the opined of has Neutral Mnctor,and W amend this Wnm to pmi Me toad name and
address of such damage commit
FINAL OISMS ION
The oWn au od to mHva The vemaled remaia of the deceased from the vematrm is:
Name Aix x due-Baker Funeral Home, John Alexander
Ahmed; MW Main Street, Warrensburg, NY 12885 Phone: (518) 62}21085
The demand Alexander 0 d see will M trimmed Of as fdknre:
Return to family
If W any ree the Person named above does her take%8 "m of My ueM remains,
Pine View Crematory is adhmizM to give relaxation Of
My remains W Alexander-Belem Funeral Home by comedy
in Perwn or by reglateree mail Donna Disisto
M&189ef(Rey oul Page 2 0 3
Authorization for Cremation and Disposition .
( the Mounted
We understand the&Me remains an net daime in 120 days ofwenwhon
Pine View Crematory may diffuse of remains in
an mmevsbie manner,such as by Rimini re
9REMATON COWMNEMURN
(�1(NNEWIhe Mlownr)
Alexander-Baker Funeral
An um to be used as a consumer M Me argument immune has Win purement from u.....-
and m emerged ea folio"
IWe understand that it Me um Is coo far hold thin eager assumed ranges,an addleonal new consumer may m used MrdaNwy.
oR-
�Mumi¢mtyelpumhasN. INie undenMnd Nan if no whim tyrtheeadwolMlwlaeprovlMN
Pine View Crematory wit place tin weenatec vermrs,In
a had temwuary consumer as detvery. I duwsn
This AuMp/Aaan Falco was provided by John Alexander was executed IS
Alexarder-Baker Funeral Home
3W9 Main Street, Warrensburg, NY 12695
ands signed by Me annual airehr as agrees to in executioner V
We haw received a completed wpy of this AWhom"m Form.
The pananp)deemed below yore the iersonlq In common M dWmdMm,who by sgnsne N's AUMa an Forme s)
W the accuracy aM c nmpMtanea¢ of the informal containetl in thin AOWoriorbn Finn ntl Something)the bMOlrrp.
Sign"fnienee M itth sera July , pp 2�
Dal R.
Dlaiato �/�\1i/rR\ham nuO
17 Cenral Ave., Revena, NY 12143 \ v
Arhus
WITNESS:
Jahn Alexander
w sw C
1W36
Oonna Disisto
Ivawoe..m
OQS-189N(Rev, 0430) Pape 3 a