Tortoroli, Andree Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: fo� TYMCAL A RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: S 11 / ZO /0
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
NAME: �VDRSS ToRToK0LT- CASE #
TYPE OF CONTAINER: tided cj CA aldlftj l0,1+11 iliur.
PLACE OF DEATH: 11" 76 110 A 51raf 4,44- 9dis
ESTIMATED WEIGHT OF REMAINS & CONTAINER 100 IJ�
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION: SI 1
TIME STARTED: (b,'I'S�h TIME COMPLETED: �Z" K
PLACED IN RETORT: /0;5o _MOVED:
RETORT # IN WHICH REMAINS WERE CREMATED: 5(!- Am PA K
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE:THE CREMATION LOG SHALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
Scan_0007.ipg 4/27/20, 11:18 AM
)qpit a following)
I/We understand that if the remains are not claimed within 120 days of cremation.
atoryname) Pine View Crematory may dispose of the remains in an irretrievable manner,
such as by scattering.
CREMATION CONTAINER/URN
(Initial ONE of the following)
An urn to be used as a container for the cremated remains has been purchased from
and is described as follows:
I/We understand that if the urn is too small to hold the entire cremated remains, an additional rigid container may be
used for delivery.
-O
An um has not yet been purchased. 1/We understand that if no urn is purchased or otherwise provided
Itcainer
ryname) PineVieA'Crematory will place the cremated remains in a rigid temporary
for delivery.
The Authorization Form was provided by(funeral director name) _ Thaddeus W. Baxter
was executed at(funeral home name) Fox Funeral Home.Inc.
(funeral home address) 98-07 Ascan Avenue, Forest Hills.NY 11375 and is signed by the funeral director
as witness to its execution.
IM/e have received a completed copy of this Authorization Form.
The person(s)identified below is/are the person(s)in control of disposition,who by signing this
Authorization Form,attest(s)to the accuracy and completeness of the information contained in this
Authorization Form and authorize(s)the foregoing.
Signed this 26th day of April Z7 yp 2
Jaques Tortoroli X
r yped or Pnnted Name
86 Greenuay Terrace, Forest Hills,NY 1 1375 Signature
Address
Typed or Printed Name Srgnature
Address
Typed or Prrnted Name Signature
Address
WITNESS:
Thaddeus W.Baxter
Funeral Director Typed or Printed Name f
Funeral Director''Signature
10227
Registration Number
DOS-1898-f-I(Rev.Otl10) Andree Tortoroli
Name of Deceased Page 3 of 3
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