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Wilson, Daniel Pine View Cemetery & CrerriaLorlunl (,quaker Road Queensbury, NY 12804 (518) 74.5-4477 or (518) 74.5-4476 Funeral [-Tonle ------BAI�G�__-- Requested Return TIllle-_-_Na& Name---------Rnti-L-I&P Case No. ----------���--------- Date of Cremation-_ $�31f�_ "t'inlc Startcd_7 3' ft) -Timc Completed--__10''00 p I Placed in Hold: �_�1-4_____ Placed in Refrigeration: ------------- Placed in Retort.: 7 Ho Type of Container ------------- ---�44`_ �__ ----f `----------- -------------- =--------- ----------------------- Remarks i Main ------- ----- Move------------ - --I-S.0 Place of Death----f z Z ----- �� a ---- ---!Z$2 I _ ------------ Estimated Wcight.of'Remai ns and Container-----___-� ---- ----------------------- Date&"1 ime Remains arrived at Crematory------------------ Name of Funeral Director or Registered Resident Delivering Remains_____`�SS-IIAmfe_41 i Detailed reason for delay If remains were cremated more thmi 48 (lours front tlnlc of accepted delivery ---------------------------------------- ------------------------------------- -------------------------------------------------------- ------------------- Retort Number in which Remains were crcnlated______________ , � ��_ Note: 'me Cremation Log shall be retained in the Permanent I'llc of lllc Crematory i i Authorization for Creniation and Disposition gre Ay;, This AWjavajon Form no be wmpww&Wngoodpw to dWW*f Mnitm tarcwnwon. Dalu, 911-t I is CrernatoryNarrie: pmevtewretra fy Address: uakef Road.,22eensbury.New York 44 12804 Phone: (51S17ej5- 7Z_ 2 — CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS. Cleniation t,,carried out by placing The jernAsrisof the dece-iseeil -111J th !1;Pd IUJ t.'l 1i crew atvon chamber-Abere they are subjected to intense hew and flare.The hew and1ame tip kX*M%Wwd c"surw ewythng w0ept bDrie and meld,Mich are all dut M be left afar avamMon. F,Aav,An g cremation,the aemajory ,-A take reasonable efrons to remo%oe an Of the rem.ain s and other material from the vAI*efy bc,set behond. T tic Lrv�,rriatjry vAJ SeVa riAte incidental and foreign Mate ni atiov chani bet.but so�me m inim a)dustand w-%*du e -a'Vitt be&sPG----d of as Material from the rem airs and the incidental and foreign nialer je :att jx1tvented into-r-lialt pw'-Vs aruJ Piated Vito ate4u required by law. I he cn?r Ad rem urn._Cremated mmijs ga&,,s y4f be rnechanxy agment IS reCWVWW-w- oesignated container or nw idly are pukrefted urd nosrgle* ske*W tissue, OPEN IN Q OF CONTAINIM The crematory may only zeta the container hoiding the tin cram atetd human rPrrrarns ae bttif rtad cuCurs lances, such as to confirm the tdenttyofthe deceased Oftoensufe that no material is endosed Mich aright aMufu employees or tram age TTA>M atory Firc t-N If human mfflaIRS are delveted In a wntArw v"ch IS not 91 11"IN MMMM MKh 85 a ceremonial or tental c&*tt,the cm,&Uxy vA to etas the remains be moved into a skWAe cmtainer before it 4 &OCaptSft MMakM 1fv Operjnq Ita container of the transfer cif rem fret(A FPMAS"!-,'4,Iw to be,fu it,a %utness and wN be done in Privacy,vAh dignity and respect. inFunFICATION OF rNFQFA-qED M apUv SM ttis: Name of De f-eased:'Tylua (A -1 Last KnovnAddrerm IL3S Plata of Death ( *K pop 81(p 119 wmj 5ex� Ew J- Aqjt'7��L�';3' I(jvX1 -7-7 Cotrugated Cardboard Box vwth PIYYAXXJ Starmark Mode4 0 38808 PERSON IN CON T R OL OF D tSP OS#TJON I arn.i We are the designated agent of the deceased designated in a%41 of W-4ten instrum. ent executed ptim4piril jr, Pujb4q- He rate Law clGn 361)1. haw no knov4edge that the deceased executed a Ywrten;nstrument Pursuant to Public Heaiih Lava sectxin 3201 w aa:containing directions tot the dispositfon Of his or her remains and arnF ve are tine prrsor s)hatatg prtttrrty undeOtr r Putkc Heatih Laos sedan-1201 and have the nght tc authonze am at*u ofthe remains of"deceased. htyr rdatWrahip W the deceased is as bAr": (lrAW from the W- bekwl Number--'5--DescnPtron: Y A person desgrrated an vutttng pursuant to pL"c Health Law secoDn 4201(3); 2.The 9trMWV use. 2a.The survvng do testtc partner. 3.Any s"Wq chAd eighteen years of age Or older; ;.A surAving ttarent ©A strnaving silting eighteen years of age Of dder; &A lavAAY apDDinted giardian; 7.Anypersottts)etgnteen years of age Ofr erltated to slt:re in tfre ;t.ttr art t�dru;pare ac st ss reiatxonship to the deceased; a.A duly appoMted fduaary of the estate: 4.A close fnerd of retatnrr vt}a tuts erceCuted a ow 4ler�<slaemellt VJrsu vI,1, p Ljr_*C He< L,+tv. 42�'-t71; 10.A chess f$> offst r r€a c ttnty ttr a pt€titc adm€nistrator aptp Hied purr nt to the Surrogate"s C o rt Procedure Ad; 10a Any outer pet- W10 is acung on betwf of the decw5t-d and Mc,haS exec4led a vfMen statement pursuarr to Pubic Heath Law§42010 1('.1� lalsre hereby affirm that the body of the deceased dDes not mntarn a battery,battery pace.Paste cef. rad�rnp pant,or radsoaMre device and that any such rra"tter als v&re remoaed prvr to the exeaaMn Of this AutrtarizationForm Faiirretorarmetheise Items OW toRt3frtt►bnmtrtr re"J"tug mtothe tseavoi fy andcrerrmury persaruvl. 0�0. IMe hereby Orm that€nstniams have been gfven to S&3rr Baker =10159 regarding the rear dvall of any personal property or other thing of'vWue vhich any person 59tung beior4 or any fafr€€ty member of me deceased r,vshestopreserve- :c• Ln Pare V4ewCrematory is not tespcnsitk for rc suet c4 peep ona;stem s frc;fz;the asnimm.-rot from the teat a rtsof the decxdtkd.Peesarret tam it"to the eontalf+et of th isle ernaiss wit be desir ed by the cmin tim p cocess and canna be retieved after variation, .UWe hereby asA prize Pate Vtewgrematgru to cremate the t ertnairts of the deceased. The person authon zed G retx.%t the cremated remains afihe deceased from the aen;atrry:s: Name: Baiter Eunice!Horne Persgnrtd Adttess: 11 LagUele tfy3 Q New Yg¢+17B(4 P horte-a(`,iL$1Zfi t � The cremated remains of deceased vrt be disposed of as bttavrs: Return to tamiy to be decided tf for any fea-stin the perscr€named abmedoes not take posses9an of he cremated rer,rWVS. Pxciy Wy r'r fl7*tilQfy' is aulhorve-0 to p7rix Of the fefNwls tr; ;r•�•�•., • Baker F uMW Home by ddwrytn per-,Dn or by registered ma;. ^.C.:,..;c4.:,.;:1 c4 _:,Y- Nair-t•::PCtx rxtsrc: :�r.:.-� Y'l led wthry 120 days of here ation,tvffel understand that it tile rm ams are not dak" m ay dispose of the rem a ns ir an i rrelrie%eble m anne r, Pine Ww�rem aiary such as by scattering. CREMAMM CONTAMERME aclukONE of te b*XWV I An urn to be used as a container ftx ft cremated feMS115 has been purchased front Baker Funerai Hcffne and is described as folw& 1AVe Lindefstand that if Me um is too sr,al to hold the entire crem ated remains,an addMonaj ricyd container may be used for detwiry. 'a'An urn has not yet been purchased,Me urAff stand that tf no urn is purchased of othenuse prwded enme Prue V*ewCremaiary M puce the cremated remains in a n9d lemparary ciantatner for d6wy. TNsAuthortzabon Pam Mr,eWailted At RAker F are at Hme -V t"qv o,,y fx .... JILAfa)&tte Street,gieensbury-NewYork and is signed by the ftmrai director as winess to is evarti on. iNiehar>,--recemdacomlietedeDpyoftti4sAjthmatonFom. The permn(s)kkiWled bdowWwe the pefsan(s)in corWoluffte0an,who bysilting hsAtWWkZ3bW Farm, MC*S),Oft aftand OJOWZe(S)the breom S"this _day ot. 20 Chf i�i�rn MS, C k- COL4 S10-fligMe-10L 2LI-249' 9d [*WIN*,W#",4 Wq- AA#rz VATNESS: C-Y\L I C I VIC-1—A Fun,en,1 H*me Reg.--01130