Keegan, James '
' PIno VIuW (��o�oiury & Cl-Clxkx.Min
Qucu}xIxu-y. NY 128041.
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NNc'Dlc (�/oox/�on
& srmrrrrrrr or:�azsora
IEIA VMK OhdSion Of Dr%#�OF mimes
STM OF Onr.r.""Wrimv Pl y"
STY. cmis 99 WsshirvWn Avwwe
Mb"ry NY 12;M(W1
TekVt"w-(51%4X 6226
www day Oy Gov
,uthorbaltion #cw Cremation and Disposition
This Aedmvftalltma Foam must be completed and i 19rwd priw to d hfmy of remain for crenrstlon.
de: Numberernslor 3Z Z
y N me.Pine Vow Cnerrastozy
Qualoer Rood,Queenebt", NY 12NM Phone: 518 M-"77
1EW►T101111 IS AN IRREVERSIBLE AND FOUAL PRQCF..S&
mnollon a mried till by pt®dng the remaiin t of the deceased and the cozMaenesr holding the rernam M a cremation dwriber wtwe
)y are=**%Wd to Willense heel and Same. The host and flame wilt inctzmete and consume+evwything erowo bone wid megrl,
lido iris aN fllelt will be Wit alflsr crasrabon.
tlawkag cnmod an,the czemalimy will take ressonst.ile o fuds Io remove all of the rerrcetns.ArW other material Born the csmrn oon
erzrbasr,but some mwwnsi dust and r*udue wd iikeiy be kWt behind The cmmakwy will sepande incidental and Iior Wqn rnslerisl fmam
a nw wirws and the irac idenini and foreign material will be disposed d m required by law. The cremated rernairrs wig be wscham aft
0.inked kft sanatl pools and pteoed irda a designated container or um. Cromabsd renweins garwrally am pulharbsd urd l no
4*how -swat is recoaniaelaie as skeletal tie em.
'IBBIi O tF IN 20WAM
a OMMANY may 0*Open ft container haid*V In un-cim,ratsd!mnoi remeimo in bnale+d omrrabantm,such as to c=ftiv the
01 the deceased or ID a~nseint OAat no material a enclosed which might wpm empl)yem or damage"cireardtory prcrwty. N
also reawbo sra delivezed in a co ntairrer which Is not saridble!or crematim such as cersi ioniai or raRllet cadoK the
m udmy wW rsgL**Voat the nwA ins be moved bft a suitable contdinw bafto it accopb Sao vmv Inw The opening d a
mains or to transfer or renvivld d'remains will be concluded Wore,a wkness and will be dome In prw*Cy,*Mh dsgrrity and respect.
EKnFICATM OF RNWJQ
no d Decearaecf: .larn as D KAegan Marital Status Divorced
st Known Address 17 Min Allen Road
ace of Glens Fells How aw. Glom Falls, N`P' 12801
x ISM ® F Age:65 DOS QW 953 _ Dale of Noth:aJi'1�019 Eked W"ht 1750
swpb og :asketicanukier m why rani will be delivered.
acrj sriaW C-ontainer basic cardboat d
RI1M IN G l"11FtOL OF MPOSITION
wsowv in cruntrr>a'or disposition, iyaitiet OPJF of the
- a aria A*are the dnrgnated agent of tlae deceased designated in a will or written wslaxywnt executed pursuant to Public
ants isw Section 4201.
q_ �,< I
' ;; ,:v7*have no knowk�dge that the deceased executed a written nWnmenl puaraLoN t*PuWic tleaft Law Sechm 4201 or a
contaning directions for the dwpaarlsan of his or her retraem and Mwe are the peraon(a)hawing pnonly under Put&c Ffeadth taw
zian 42C! w4*'wve the right to aul ooze cretr Etion of the renal ns c4 the deceased. UyXkK retatfonship to tho deceased Is as
Its
-S-18W4(Rev. OW15) Pa0e 1 of 3 i
v�s�rarrwrrvr• rv• wto.���asrav�� ar�srr wrvrrvrervvr•
L�Ilerf'�frl��ba10YY)
' 5
A pNs m dv*p%WA d m wrOV pusuard io P'ubk H+aefftr taw SKOw 42+01(3);
The mvift spouse;
_ The euvMV dotnesfic.partner.
Any mviv"grid 00 do& "Ws of SW of Hider.
A eurvivirrp afbffrrp e4sow y e em d ape or cider.
A tertft g4x*red qusrd w.
Any person(s)wedesi Vwrs of ale or odder errMlfW W shwe 0 an eirrfe and who Wom closest wr febborWV b tore dea:aend;
A duty apporded liduciery of the eat;
A does Mend or aloll,a who has#awcLOwd a wrMlan sUftrnwo pursuard to Pubilc Hoeft Law Sedliion 4201(7);
4 A Ct'*W tier*oftkM of a coo*of a pubs adnwnVMM appeirAad Punk nt to be SuMOO S's Court Prrrcedacr+e Act
vL Any o#'rer perm who Is ec6V on bdwff of the deceased arrd who tars aw oAad a wditn dubarrew puetreot 10 Pubft IOIh
Law Sedion 4201(7').
dW ALL Th REE of V*l6rMorwirrg)
lMllle he""firm dmef the body of the deosesed does not aordam a bebery.,be4Gery pest, power ml.reffm We anplsrlt,
adinerl device end dW any such mak iolai were ranraMed prior to blv azea ion of ftsis lunohoubadon Fomn. Faik"is two"
ew ilwne prbr in crr+engr*m nn"rem*In Nm in Use aunaery and crereetrrrry pw*onnW.
IV*aft. 11-M ivafnuium have been griren 10 Pebtcis maw
_ i MOW.+tYrs�.Ahrr�t
go all a 1f'ter laercharrai of any personal pmperty or ctlrrmr tltirr8 of voko which arty►person signing bak m or&W 4aP*member of the
f wlarhea b preen we. Pne View Crerneio y -
not m apocu bie for 1f a removal of Pomona[00rrs from ft 00nuwww or fmm the renwo ns of the deceased. Par mMd lbarie kit In 90
mftk er ar wilfh#w mmaku wrill bee decrb vy+ed by the a nedon pr4cee�e nerd ctarmat be ra6isysci alder cneagrdoet.
1 C IA, Pure View CrarrMakry
'10 Me
_ n +�•+ar
ONNUae the roeAaine of the doicam ed.
N14.99MMIlnQiw
"parson Su#Wdled to remvrs ft omnu and rsrm*w of the decemeecl morn the ownMcq is:
Efne et Funetal Home, Ire fops eer tbee j
24 ChLwch St, Lake Lug, NY 12946 Phone: 515-695-2744
're trerrretd rerrrairm of deceased vAU be disposed of as folk ws:
darn to fientty
for any reason the person two aboare does not take possession of the aernaied rernams, j
ins View CnKnokxy is authored to gives posessaw of j
n".rnrr.�r Mrd+1
e nrrrairw b Brower Funeral Hoare. Inc~ by do&WWV
tFu.war+4vnr Mb+r•V
parson or by rogi kKW rnail.
Junin D. Keew
r».1MORI MAW none
�frsaaaw rrosr�aa wa tira�ea►aassys. +as,..v v.vrvosawa
Hie kwm*lo
�k
O*qo UV*urKM suM fun ht thenwwwis are not ciairned wdhih 120 days of cnrnna m,
_ -_ _ may clapoae of the nwru*n in
n wrolrWwobe nunro .such as by erattn".
MENAMO 1 OMAN1EMON
i"ONE oft o
q An urn b be used as a cordairher far dhe cr mvftd mnam has beam purcweed f m Brewer FunenM Ham. Inc
rod is dehhoibed ae foNom.,
V*urxWvftW theft if the urn a lao srrW to bald the in mire crernaled rernans,an sddi xvW Ind oontww may be hrss4 for do way.
lwl
M um is nor yet punIm eed- WWo understarW dug#no urn is purchased or+a wilt pro+rkW
� --__ wi pfatae��rrrrawirrs in
rod ftwWon"mw**w for deireny.
P Miur Ymn exomftd at
his AaG1or�,afrfonh Fawrhh wes prrcwtdrerd by_ _ �_.. _-._.
r�+�s.ear,►�baer)
irwww Fumw*klor w, ik►-
4 Church SL,Lake Lu mnle;,NY 12W.
id a signed by Wo UwW d1reckir as wirmm b ita evaoMn,
0*home mosive d a c ompktod copy of Phis AuMminsOm Form.
he )klowA Mled befm ihgare the Porwrga)in etonlol of dkpn IN, w1w by mWift W"Aofbodoftn Forhhh SUM*)
r the accuracy and oohhrpi■frna.of the kdor natlort contaknd In this Audrorhwdan Form and auftwbof a)dw t*t*9 h
Wnd t#tfr 9 my a May _ .20 1$wear�41"In
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'ETNES�i. '• �
arrhaa f1�Ner y A� .t.
ewtMit"�pyf7a00I �YlMP •rr.n�C:«�+s'.�".' „y'VR'«"C^��{
2465
James D. Keegan