Masters, Rose r
C TOWN OF Q UEENS B UR Y
Pine View Cemetery and Cretuntorinnl
21 Qiinker Rond, Queenshrrry, NY. 72804.5902
(518) 74 5,44 76 (518) 745-4477
htrp uwNvw queensbury net
Funeral Director: lily /v*v �2.IJY t�l
Name of Deceased: ')QtG j E, AA
Case Number: 7i
Date of Cremation:
Retort:
Time Cremation Started: 4 s"Q -AA
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Time Cremation Completed:
Type of Container: C-Aat-v--�) "u>6;4\Z-UAdP'l wt
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Remarks:
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Ho e nj Nntirrnl 3enirly ... A Cool Plnie to L �
From WMMar'.)t its r,,-on; ;n(:.
PHONE No. : 518 873 6713 Ju1.25 2005 3:41PM P03
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_ AT1O'V FOR CRF,MAT1ON AND 1)i41'O�I't'iON
AUTHORI1OCOtkVlStitlit ANI) hlNAI ' i1.A1► '{'fttlti t)l)tI;A11+N{ tMNtil'l►N(:1'kNW(iC'RlS114;NION.
(.:kle.MAN Ih Il nut:hll. , IIETl)Kh, wiliNlNl .N11 '•'19I14 I4 A)YGAI,If()('.IWNT.IT('( NITAINS IM1•()Rl'ANT>E k()\lilt)
1(Wl„lhr.ultrins:ignrri• Mily,tuail'Iall and mltmscut thus I/Wc lrtvc thr f to 11.tp.,I tip it and:u th„rtty,a+ui)n1w •,I m,tn•u,t•,I+g+•.,n,.•hu},u,ct.ul't l,ta}+r urrl}'right an•i
lt�ili4{(M,.W aullll)r176:ll7C taut,ldltlxt,laYfolp'+'UI1}t 111l(I llliiik+alt,lxl lli Il K' rciitr,nl.,ul �•i r' • �'• !;l J,d 14'� .
(I lumillaitcl.mfurrutt u)itv 111c"I Afca,iU.Utl";. r-1 ° l e/
G) M 1�•.(11:t►!1.x:adt j�Ir � `.--� 1'1nt a1 1)chth. A.M. ❑ 11.Mt
1/Wit Ixvvby royal xt urul auUutrirr._._! /Ymnse.""is' SG4'l f —tnJ( tlx nin.ttrcy'lcicrAM to its ttlu -I�uurgll 1 ifxnc")to IM;.
WW' nlI;I,nrt*lIIe.'c /, 9
I.K)\tiCSSitvl of mill!inako aiva l)�(,IIIGtIIh t'tN'LIIP CrWllJtitw tot the mntain4 of thc.I]I:CrY'a'rl nl '`�/1�'1 � e ry l!A•q,.Ini1
I lit,rnitlifiel,10entt d loa/:Illc"l:runlalt+:y").
i/We hurehy unihnrivn The Vrernmtt)ry to rultirn the urcnlatcai rest ulinr: till the Dv(r"Ij t,d to tit, 1 ,nt?hiou and t•u.ful;,• t1i div Fullclllf Ileum
I/Wc unticrklarxl thu(th„tK•1't')V4A and Ol)l]Lr,tNitlllh n1 tits,CI'G177mSb1'y tihall l,l'.fLlh lllt'.t{Wtlt-u OR't,t'III:IIC1I l l't11:1111ti III Ir'c lk•Ct'aSCd NI'.f 1'G11111tdi tp iht'I)I)ti%CBSh>it ill" '
('llt:lLKly tlt 1}IC.l�tlt7[,t'a I IPnle.1fWc�IYtpt�hy,.adhurizti•111a 1'0111131.1 1 it,ne,,t+,n„nnf�t 1tn ,In ,Inlunrtx,,lt u1 lhr 1',t•1nt,l:•1 n•nlyntR t)1(tlt'I11•iTil.etl 'Tl 1'011OWS: I
!x rpec ixl]u+ndlinp,nYluinvl'r ❑ Yrs.k Nu lkA:crilx. "--
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i k nail lion crf(nit ur(oulnilxn'1K ktcatx
Suilul)ltr tin)dtilq>n,t;; ❑ Ycs Nv
❑ lkdivcrt0,.... . . t.'anxncry
natu„ md nmro,.,�d c t•gu le r e
❑ ltt!h►Atr:rbfArtlily,,,_ __ _._____.. . , .-.._.Y.,., ...
Nanw ia'Ikoia,aletl fmmi,y un,ni�n b�lt.,,,,.,t7cu,.d,d rtr,:un,,.
[] 5aatuslvlg&I w by Fuwmal lloiitc.tar funeral I1(uum:n awsat
❑ Slid via U.D.R w•od MqU* ..
'ur Nitriw W-l.!Z . AddreNs 'P t) 0<•>• 3 ell 7 1 '�. (t Z A
•Ametal llnlur tend Crtatlaslory mriv not 1*913►Ire:ihk•hw Ally hits', 411A 71, of t rrr,taM'd 1't n7airn shippt d t i;l titytixlrre d A7ait with file It hlih/l tilrlrs
Thc•crof llilktn, prouunaitig tind dlspnxitlon of the rcr.nlains u1 air Ile i cam(I dulfun vi ri ht'161) l luill he PlIrrormcd ill acc olduipc k: with all
gc,lveflling Itiwx,Uu+tilt:.,rcrp,ulttltcrns an(I pnlirics t►1'Ihc(''rrnitrlort :and 1 7 n riil Ilonw. :Ind the fol]owillg,lernis atilt]condilion,:,
I. The remainm of Ihc:lZt.cuurtetl will nut be ucc(V1►trd kil' Crc i,7atio1l unk�� ri r<•ivctt i, Ihc ('rclnillory in it c(►mhtisfih]c,loatk resimallt_
rigid oreantdion container. Thr..('rt.rnnlury it authori/cd to rorwwc ,till digpo,r of lr,v;iidkv: orn:unrnix rind wiy ollYcron
r, coinbustil-ilt.
itcnts aflached to th0 Crenlatipn ctc)nl:,incr[)riart(1 rrPnlNlitin. fit ihr t yr tl 11r It invin:• "t'llic Ih cx ascd arc.lt7caavC-d by the CIMILLIM)
ill a caxkat or other container cotwirtl(lted of lncitll filvi-p,l;its, ill i4hi.-1 'ltllh'(1lt11111t•tihlt' )ltitl('d7ilS, l;WC iltllllrttiA',Ihc' r'(911rtilIS of ll7t
j)c%eaxcd In AC rerrioviced pritsi lu crerniltrttn xnrl phl(.cd it S' t'.t7nh.)rd h;1. 4.Ic'mnii:)n i:oui'lillr.:. I!Wc I'ur'lhcr aulliori e. Ole Fwic.n,t,
Il(unc or C'rett aat(iry to make dixpoxition of +trig rUch n(lnc.ofllbu~tibit' r:sl ri i 7 n+�' F1t('!uT nlnnnz r it cicxlut ttpplolaiule.
2, Mechanical or radlaia(slive ticviccx implanted in lir( rcnrtfns of 11ic I)t cca nd r.0 h :IS pact nr(ki'rs,tlr.) nett'!' e;cnSc a 11,1vard WIM.
placed in the,cronealion ch:rmher.Tlw(+rcnrtlory Will full cri-Ilet111':Ui1 1'll'i17:'11 1'cillaill!.:which c oillaih ally i j 11i`(11'I1111)iMIICd 117CGilallllG...
or rudioaclivh•device, in Ole event the rC.T11Mnc n1 (he 1'lc'c'c=a.od cw1l;4in .tit'tt .) tl(wico. 1/Wr belch' htllhorbc Ills Punc.rai 11011e• iu.
agenl:i an(I urnploycca,to tctuovr.;any stitch ulct'hanicA! drvii 1 t, i low It)(. I(•1111 t" ttf Ow l)arils(•+{prior'lu cr n 'ttiuu,dnd dispose n:
such ileum At its(til;r.rcllion•1/WF Illadl?11Y C'F;12T11'Y'l'Ti•A'I"f IN' 1:!'•MAJN5()i A) a )O N(.7�'('. )N'IAI:k.
ANY 'I'YYI?OF 1MPLAN'I'F.I7 MLC'liANI('Al.()R KAUIOA(:"I'IVIt 1)EVIC');. hICASC iniftal orlt:, 1")i� j
l.ixled below arc till implutlted nxx:Itanical attd radictactivo dt vives which the I"tltivr'al I IYnuc M,r,ulhttioi l F t t^rcnitdr►s of the
VeccaRod for to cremation,and dis w.of ag indic AW: +'�q
Ix lw . K �
....ipliun tB htyAWYat11A,ia. I�y1O•a"•,
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tkru'igMkund huWinprul,•w,v .. . „'•'"'"''"", .
If no inkiruttticin fir dhipo6tion is given,such iterrin tility h(••dilrponcd cri'r( Ihc(liNCtTlion;*it I+uncixi H(nrr.:.
:�. Tilt-,rr17n►alu,n CUultlint rConleinini!(Lv ruuuaiuri nt tht+ik+ouuactl will h< t:lnc,.<t in tht t,cin„ )MMI)t'l anal Will lx•It1(atl)'11110 fl'I'c`C'f""lt;,
dcwlroyrAl by prolonged axllacurc+lu intc►er('.heat Surd direvi fllilnc• I/l'1'r-em 111 lot ire iht rrry►i to k 'it IL'c c:rolwiliull clirnnh(,f during tilt
crerntltlon iVOLCSK Sind mIxrsilion the remains iif Ihc DiwiCatcid in oicica to lilt illi;itt' a'('r.,1ltiflctt Su,d t utrnugh crcnutticln.
4• Cterlitin ilviliN, including, hill not litnitcd to, IttK')' ro4Hu•ar. doilltm-N, tb,,r►lel hridpowori, t c�lilid !'111iligs,jk-.1i �, told tither IM",011sf
al'Ilclefi acconlpal1yi111t ilk rcnllaina of the I)cc.aasc.,, nitty tic dcohoyt'd during thr ('Icullllioll ilrocc.-& liWa ullhrr aulhc7l'iRC 1h11 if aril
Ucmx, o1hCr lhalll the cn:rillllCd I'Bltttiiu of the 1)ec('•ASN). are 1r4 oveled 1 o)c l flit' ricnlation chamUcr they neay kx xclru:N:d 1'rurte ill,:
cremated rummies of the 1Vcccasc d grid dihpuscd of by the,l:rcrnatory.
S. 1/We harohyy nuthorizo(he Ciomnlory I<,.4epurutt•on,i rornovr.1t,nn tilt t 1-111,11 it lotelnlrrlit('r ell rwncolllbusf ihlc tuaicrlals•inc'ludil?F,but not j
]ilnilcd to,hinges,lalr.tles,nails,jew'0ry and pliccious rnoials.and to di%lMSt•.of Such Illawlixls..
[,. 1.ollowin,$cenusition,lho civoudlid rointiin,:<+f Iht•D4.wcuatcd,riAN,i-i*t1g printarily of hi rot•1-011Cnl.,will!x' Iut('hanf)c'atlly pt11!'c11/,cd it)ail j
unidl�ltifulhle consislcncy prior to placenictil in an urn or olhor eimtainor,
7. l litli!Rx till urn Of container kuitahlC 1'(lr r:ltilwwnl iu plir0,h(tfKXl,ill(,(•t'nnuif,u'y will I-)111(-t-Illt-r7rcauawd r-t inilina t11.111c I)cct•itsc.tl in it CtllllfllllP'.'
W11ich it not dcsignated IDr'Stay lyjw of shiplilelil.
K. in Ilk•evPAll the tarn tit'ecMWIIIer iN insufficionl to aciv oltirrlrxiviv u!1 of IN-,-Fi-midrd n•nuunc,of dic I)::ccehcd,any cicccs.s c rc Ina1t'cl r('lTitilh!;
will tic:.placizA In a ,vCulndary conlatimr And r(•turned io thr• I-uncr'ld Honec•,luy('lk 1 with Ills I,riRtttl'y lift)(Jr collf:IfnGL
n rnr1 ..... ........... ... .
1/Wc hereh}-ttalhorir,(-the("rcwmory I disp oil t,I ally 4iwh ret WLPaI ilat'lk 1C." iri;illy Li4'110 Imil'llk'.1'it dq('nik approll isle•
lb, ilnhrhl/wu};iv(,Klxa:ificwrittwtinsimc.liollsilllhiKAuthcvar.alwn iht•.tavimllinn In r1r.I'. ,+np;nutdiyu+tiiIiolt(dthcrcurailrxo11111! 1X!Va;l�r(I
will not be Perfurlmd in accordance with any particular religious ious a ethnic cuaonls.
1.` },I 11tr.event Ihce cix:mated retnaim;of the lk:c o4ed remah)tltlt,Milled I'01 li 1wriod ill'10 d8yY,OW VIUrcrtd l lcnuc'111,11) ,rvr w rlllrii nalwe it,
me/us by c:crtifu:d tool; at The addt•esa(es) indicated he•.low 1/1W ;inicr Illm ill Itic• (•rent ilu•rreolr.trd r(mains of Iht Ikcca�ed relrlaill
w1clitimn,for it period of l�fldtty,v aflta'0K•Qau. tilu•h writtr'n llol&,,trir,r:%,,;;lieu!,tilt I tlnc•1;d i lunlc•ir.:m0lm i/c•cl alld dinrlccl to dispunc
of the unclaimed wemated remains of The Urtx*,'ised in any lawful mama it way deem appropriate.
12. I/We 8 reY it)indemnify,mic-one and lurid the C•,cnlaiorv,lhnlarvl Mont,11wir ntfllkillt, at'urit!"k'niTiloyee"itild uv�it 11minit-i', from any
and all loss,dwnagc.s.iiahiiily or c:ct,rc.�of aclion(inv lldi 1p :41lnrncyl;' iel.,,and ell iiiglaliov) ill i'rtnnt,r'.116il w11h ih5'rii•Inatinrr
a lid disposilion of the.c'ramalc.d rcmalin',of the Uccctt,rari,a��ullholirr.d lu•it•ill, ill my/om t:iilmv in t-on•rt•tly idowify tilt•ronains nf'th(,
1)rc;cauec1,dis910sc the premlec of any implanted Itwchamual m I:Iililuu•t wr duvirr\ u1 itJ r l«1tis.r•tiYi(,I1 of,1.11 MNV Iternianc•lil arrangement.,;
for,the disposition of such rcmxins.
11. Except as Rot forth in this AutBoriaxlion, no warranti(%,exprolai:C•d n) impliod ark, 111miC itNr thl'1-Inkral Holm,('ralnatory,ter any of their'
rec;pective affilialm agents,or employees.
ICI. I/Wa nndtsl-Rtantt That thiv d(wunlont(IOC,ttOt coninii) is c•ollipleto rind d(k(Plled (h%Xvr•ilstm;) A every llhlrt•C.l of IhC c'rt ntldival 11>rocxakv. I/Wr
klAllowledge retviviuu, I•nrnl the I'unc.rrll 1101114'. t, ('airs of the haltk{(I rnlitlA ••1'r5•tllmit'll t;tt'r�rr (ontaininf; .iddiIi(1))ltl t:x1)aj,ultor;
informalion about the cremation prncnar..
SIGNATURE OF Pi;RSON(,S)AlITHi)RIZING ('REMAT141)N.4ND MSP0,4:1'1')ON
I We warraul that all rcprmcentadonx and sin/onuenik mitdo heivin a1P Iltle :old curtroct, and that 1/u•a h:wc raid an(T undcretand the
provisions ctrltained in this;dtxunknt,maid that 11wc him.:mvciml t1w.booklet(uliillvd"C'lonl.uian 1
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r 11ini tialy KrlMnnu:hlp In 1kU'rtauN4
Addlrsti'"W�. �o�q sut�i�"' ��1, ��h�;4 �'���, �crl 1 1 lC•I 'Vcl � ) �..7�1�� ���j ..----•
His, M.M. Irrinr W5M1115In rrr'r nK'11 ..-...--.'.
Address., . ......._..... �. t.r,.� I�' li•I No.
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WiTIVP,sS_ ........ ) { �' .�t �.� ' �. �"�i t �i lL n nx' l rn }`� o� zn_ QSy
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013N.90 Rev(W)
WI;t'I'n; C.'IEMIWWyC'lyly YI1I1:1W t9•nv lr r\i Wn I'j 4K' I.rrY.rxl ij e..1'I46. fK)LI> I.�� i
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