Buhler, Deborah Pille Vievv C"'I :el-y & CI'elTlatOI'IUIII
(,quaker Road
Queensbury, NY 12804
(,)18) 745-4477 or 0)18) 74,E-44-76
Fullcral Holltc
Requeste'd Re(.ul-11 'I'll le 0l�t
--- _ _-_e - --- --- -C;ase No.
Date of*Crelttalion_ _ -/-9------I'inlc Startal_/L!7�_"l'iltte Colltt)Ictccl._.._;z5S
Placed in Hold:
-----------------
Placed in Refrigeration:
Placed in Retort:
Twe ol,Contailtcr ..__
--------- ���°� ---- ----
Remarks
Main Move 1 Z �-t
--------------------
Place of Death__
Estimated Weight of' Remains and Coll lai11C1'___1�0
Date&"hlTtte Remains arrived al.Crematory_ Q_y� F
- ---- 1- -------------/a--------------
,
Nance of Funeral Director or liegistcrul Resident Delivering Remains�� �L �L,1,�,,,c
i-----------------
DcGtilcd reason li)r delay if remains rverc cremated more tllalt �I.8 IK)UI'S fColll t11ilC Ol aCCCd)l'.Cd
delivery
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Retort Nultibcr in wlticll Rcluains were cl'cnlatel__ --------_----
Note:The CI'c IttaliU(t Log shall be retained in (lie Pcrnlancla file of•(Ile Crematory
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NOW YOWState
Depaetmw*of Mau
iVision of IJnAMN OF CMEaRIES
STAT$OF One CMTO M Plaxe
Cemeteries MVAMM"Atwue
Akww.NY 12231-000t
Tdephme.f1"474-8226
_ www4"-PV
Authoriz#ion for Cremation and Disposition
This Augmtodwe Form must be amnpfe»I and aid prior to delivery of remains for awns &
Dace : '� , �O � ` Number:
Creeretnry Name:Piny VHW CMMSWy
A zf VAkl�- _ �� �� one _ 5 1�-7Lh=yt/�7
.CREMATION IS AN NotEvEnumm AND F1 AL pROCgsS.
Crarnation is carried aut by pieang the rernelns of tt deoeaeed and tho=tamer hdting dw remains k*a crama4iarr dtarnber where
fhey ar a aubjedad tQ b ft heat and ame. The heat anrf tie wM inchwrat end consume everyg ft g=W now and metpk
which ara ah the#Trill ho left Aw a nw aftm
EORawing cremation,the MMUk y VA take rye etbrts to Mare as of the remains and oerer mated11e1 firm fete cremation
dombar.*A name MWOnd dust errd msWue nail Mo*be k*b&Md, Th9 cra MAvy%W.aepoWe inofdmrml and f»my mahma firm
the remWft and the accidental and foreign n fai M be clsposad of as ra**W by law. Thp Oemated 1019i 6 wig be mecharYroally
phverkod M SmM pftw and placed M a deggnMd contOw or um, CremaW ranWna ge raraf►are pub odked until no
Dingle*29ment Is tgooanbWe as skdstal tisane.
t�NG OF tNE Atp1ER
The cremdary may only open the carer tKd d'irrg the urcrenv ed buam remains In lrnl U dnuTzUw= ,Such as to Wnikm the
Identity of the deomW or to enslme Who mated is wcbW whkh m%K*m w0byeas or damsge the tunOW prop¢rly. if
human remaine are dWkwW'nt a container=000 is not suitable for cremation*Wh as cwamontal or renW caaket,tine
gory v M mquke tha Um remains be moved into a suitable container befir!'e It e>xepffi the rernaiM The opW trg of a
coat kw or the 1<iifW r or rm o d of ramhw wN be eondraasd bOWS a Wft ess and vAl be done in pmeW.with dignRy and respal
a]EKB%q 1MQFUMMM
Name of Deoempat, y."a i'A-J M. - r v r+ 1 �� ARarital Sim UEvar���
sW 0 M %F _4/r DO&4 �6& 1Q 5 DateOtDaWr 06'& V-OI EstimaladMWrr I Av
Description of MkWcMWAW In Which wi dns will be dalMved
r ke-oc& fi�nA7Tuv �aN7ei�er 4.�co�i �ppkd C ,Yp/�r� _--
PERWN 1N g2KOX L.OF SON
(P@fWn(a)in o01"of rya effog a►Nlal OW of mire foaowNo
.�- , ec� at I amble are the dened agent of the deo�sed ant In a wN or VAMM ivftun OLMOd PUMLOtt io Public
"can Low Secdan 4201_
U to have nD knowledge thatthe decomed end a w Man Invounrerd pursuantib Public health Low Sadbn 4201 or a
VIM corn dk eMons lbr ilia dspostlbtt of his or her remains end M are the PerM($)hMft ply Under public Health Law
Section 42M and have the dqM to auum&&creme6an of the remains of the deceased Myl Dnr retatiord ft tD the dec%w9d is ae
1'ohorra: t I
I�+JrI I Er—
aY�e.a►neoene4 --
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Au#hor�rdon far C�natian and Dispc>��titan
I.
�a>e gStDetoerj .
in ptmmgontl Pdit Head!Lew for,4Zn
U 710 SUMAN domesfcpadner,
4. Pf 8�a�da�r;
lL A su dit 1 of she or alder;
7 Any pmgon(sl eigtMmarr yearn of age or alder erred to share in the e666 and vitp bMwdostmt in reldbn tnp th TO dm=
k A OW appuKW f dm:Wy dime
8. A 116mid ar rigf8t A who has mcecr►Nod at won etat m&,t prm+nt to Public ElM%Law Section 4201M
A at6d fiscal oftwof a aoarny ar a p-dft admirrshalm Fpohletl far=ff ti*ifle Srn Qqm s COwt Pr0m&M Act
Arty other peaaotl who IB eclirtg ort belts dlht'r>ena�ad end wtla hos�lp9p�!!rt a vrr�len matt pL=sm tfitl Public Hw t
taw Sectit�4�11(7}.
Trp4�'of»full .
herieGy AM that the bDdy of the da0ae d does oonlain a befloy,betty pack pmw ca .r fteclive B'a*nt,
a raLyoBrsvB dt;YlCe 8nd filet 8Ck1►StrCtl rrli3l�(15lS vrere rQrTM01►��tp thB E54Ad�On of the Ar�iora�bp lorrn. far7tt+ne bo nartrroVa
them--'rrrs prTprlOa crrt ermp remelt nr bairn m the tvnetnet6ory and perry pearNlel.
UWe arm 90 M*Udm have tram OM t4
regOft the MnO of mW Pffimnal pnperly ordher Oft of value 4wh any Mm OWft WOW or any hu*mwnbsr of the
deed videm5 to presmve. P�9{flew Qertrrdrtry
tommEbwOnd
Is not rmwrmb*forge rmnoW d pws mlei ftm ffom the otetteiner or from the remalne of the deceased Pomonel Mme left in the
contaheer ar'vAh tm r will he deM aged by tft p mcam and cm md'ba able le eel after crarna&a
r
110twwadlormQ PbeViewCt+erutoly
persarr �na f119 QIalrlelAd rerllilrl6 afthe SOT llle ar3rrwtbory f�
Any SWfrom the Edward L.Kelly Funeral Flume
Add 1019 tS RL 9 PO Box W Sdnon Lmla%NY 12870 Phoney 518532-7177
The cremated rerr�ts of deaeaaed rrlM!le of a
.rr
vad, ,e JJIANA 12u`1f Imo-'
IFtOrany reason the cleated Ahotla daQs n�tiadae posserseiort dthe pemsted rarmhm,
Pete viiew omommy is au whad to 04 possession Of
the remft to Edwwd L K*Funea Hone by ddfverp
in person or by nosbmW mad.
�p��
DOB-lasm oR OBf 1.71 Pegs z d S
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Authorization for Gmemation and Disposition
7!7UM wvw�Rat if the remains are not chimed wmn 120 days of awnation,
Pine Vow arm"
may dapow of the remains In
an irrehtejahle mwmor,such as by s attt dng.
�EKg WE
An um to be uSed as/a Cont>`aner farihe fremat edd nNnafm has been
+pWA=d fran Edward L KQ*Funeral Home
and is riescrleci an rolows: ,Q, C ✓d�!1C1 s 1[J Y 'n g! r �—
T
Uft understand that if the um is too amen to hold#w en im Cremated remains,an addfiond rigid a w"ner may be used for deFwary.
-Old
N An urrr rdtassd ifrat p rro run is purdrased or ded
the crenated reraalrts in
pY me dpmm "
a rigid temporary awaainertor dellmy_
This Ar Umda0m twrm w=ptvMW by (� ,eye—LA Nn - vas at
Edward L Kt*Funeral ldorrm
1019 US Rt 9,PO B=54t3 Wmon t ilea,NY 128M
Hemel�er�
and is signed by the funoW dnwMr as wV*=ib its acec ubon.
Me have reoWved a oornOAW Copy of this AudKW&WlW Form-
The perwXs)iderdifled below Wwa the pates)1p of diisposiffm who by dof tlB this AerltmbMan Farm,atfiw*)
to tho aceumq and a n -pkftreas of than infwma6mR!oont*md in W*Authurmli=Form and wAborlae(a)the fraregob�g.
Sign - P day at S�P• .20 19
-TDMIAAt,
E
SONIA-
r�dUtr lgnlp
W an.
7C
14 iz 2 q 3. l-��+-A�
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