Cascon, Hirah F. - 65
Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: rOX fi��d nw— RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: 4d60-m GI f7_q(W Z0
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
NAME: CASE #
TYPE OF CONTAINER:
PLACE OF DEATH: t\40,c e Nye 13 `T
ESTIMATED WEIGHT OF REMAINS & CONTAINER �b� Q�S S' lea/ Z 3 1,5
PLACED IN HOLD: Lu Z5
PLACED IN REFRIGERATION:
DATE OF CREMATION: 4/"2 9--?1� Zc1
TIME STARTED: TIME COMPLETED:
PLACED IN RETORT: ,l/�/�;�M MOVED:
RETORT # IN WHICH REMAINS WERE CREMATED: /�Dwn,- ��le
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.
Auth(>nzation for Cremation and Disposition
js
TV*AuVwUA&w Fwm must b*CWnP*W and sign"prow to dW^wy of ronaiins fw crwn~,
Nu--iber
Crefristocy Name pttw % ;c, ( to
AdOrM 211-Quaker K,,ukj wr-wur 94
P,,24*
CREMATHOW IS AN IRREVERSIBLE AND FINAL PROCESS
'-#'
Cry 4 'Vr''J: , '-:f! a 0! ?X
t�vtrn ""ber *lh"triey are subf0cW tO 0116fIll-e !'eat and#lwMv The haalt and ftww WWI Incinerolloand
coftunw evoriftng except bon* and meW. which are all thatw0l be left aftwr cremation.
FoicwwV ct*n~ * ", lt� c, #t:,-,". *f,� efloo-.s t3* re-cve a-v: orter --latvrfa i-o-
Me cremaillon chomoor NA tc-rTv ---nsnaj ati's! C *III 4oKt-ly tw tel* T,-e cre-nAtcn, A-1 arate
IMCX*016 W*4 110regn Matenal hoel !hw Fornal"'s afwl !-c Ano A lw�zl De d4scosspo I#as
requeed by to* T",,* teem Oted emaing *jj! � mect,'wN,-Aflv tic vverlzecl ?,ltc Sri* ()"ec*% imm rs'ac'ec 'M: a
�*sfgnatf?d c0ntat-,VOI a- Cr*m&W remain*genefalty &r* putvwtz*d unul no%mou frogry""ll is
40 skeletal ftsue,
'Pitt crematory may only or*- -* cr
at to t;onfirm, tr*Klentity -,4 tilt® aecca"ci x Ic e.-tsure `!ja! F 0 rn
wlttri-, r-ght tntur* iimpioy"s or
oarnage crematory corooertv If humon remains are delivered in a container Much is not surto'bis for cfe-MA"n
such as a c~Kw"cw reft"I c&*k4K the cremmory v**I McItoro that the remains be mov*d iffy suftble
CQ"Wkw bOftWO tt bcc*pft the rwmnt, P. wenN of J ,.cfvainef 'eq.1"viv ofrcrratns wA rw
corovcled before a i"news aw,*o *)e aon-e in
WiNTIFICAMb Of DECLASU?
N&M* Of Doctated I
Mar!a `-Aatus \c,c: Marricd
Laof Known> s
Sex OM OF Age :)0j3 Dale Dea!s, —aled 0vvt,;t-,
U*V;rlVt,0r` of CaSkeVocr-lainer r,
MRM ltj!r.(Mlg"Qf QjAEQ3WQh
a(@ plt*deggratec agent of 1,110, loec*ati�d 4wstgnatej ii !,,t
puruwlt 10 p4vic He*th LA* ec :i
-OR-
hAV* n0 MtnkrA*J0hf-Ve*MAI Me NV
I -*X500 exer'Vea a
Section 420 1 cx AN woll cOnlaining lvvcl ns fv t-v vtspos*icx,, -4
tits 0( temaims ar}J
am we art me wsona%1 --a,,
i.,rooe" P-tftc SOC*tor 42C 1 A-v� t-jave i,�W, +,,to au
rernawn's y trio ceroased 4 c�.,
'*Y'OUF r*Wb(W*hiP to the deceased is as follows
Nuribor
eQntm, 'tears Q,
i A Pursuan!t_, pkiCW,:' Hea
2, P,*survtving "use
2&. T),i* s;jrmving
eigMeer years o, Age cff �,je±
A. A ,g
6-A, Yew's .at age X r*)Q,
6. A**"y
POMOVIV "Now- p#a,,sY Age :71 rl"Ie' sha!e ir Inr jo, .5*, St
rO
6. A eq kluoary 0 . es4ato
he
V A c;ose lr*q-- or -ea!°ve *hO 'aS
A
10, A m4fliscai L&#v §4 2
PfOOOdore, Act
10a, Arty OV-e, _% .All of !-,e a--,j t.
ah Rack 'CPUnsu&M 10 P'4V4C �-*A-Tf� a tlen sle4e!'wll
AL,
-Olereby at*frl-) thSt t'�4 bWY thP C4KtaSe-j 4*7)eS, nOt L�X-14411, a
_e j
fib*NDaCt,ve 3wvice a iota{ ion* S,:t, -14bt fs WL-e t
Auftx)(V-014n Form Fa"re to remove tries*"MO PncW 10 cremabon may result in harm to the r-rwmgtory and
Cf*"U%Wy pwsonrAW.
- )e INVO f1weby al ff-irr mw -ssruojnrs nave
,eg4ktdmg t,,,* rwnovs! ��,j ant D e(.4,ma -C�,L
.,-roperl,f Lv vlNer ri-,N V
"r"bw Df!he de-OvasOd-#ffSJ"*$
r**Pon**Ae by 'OmOvaI 0 Pelsoria,
Personal vWW"S
Iv In the C*V1ftO"9r CW Wft the remains vMI be destroyed by the cnitmation PrMoss,and canrKYt be retrieved
Me hw*bV authorim
remains 04 the d*(Apasod to Cremate the
FINAL QJIEMK)h
Th* person auMo(Ized t,- It,* IMO,3 e_ 1,:,
Nam* i ,vic !-f+
*v! Oe cspcsec cj-f as toji-cy*j
41 hk- dtncrnxk,'O
If fO( Any mason tiv peruIn nanjed a0c�veJc*S rx)l 14iff, cM:tSsew:>- )t♦t*v
,M�- -1140-v 0 'W" gi,.v
1-wok %--W-4-w t)y PO'Sorl :)t by -lau
(!ems the following) ( '
--)IE—INVe understand that if the remains are not claimed within 120 days of cremation,
("efr'aOn'n&"e) Pine View Crematory may dispose of the remains in an irretrievable manner,
such as by scattering.
CREMATION CONTAINER/URN
(nid I ONE of the following)
An um to be used as a container for the cremated remains has been purchased from
Fox Funeral Home Inc. and is described as follows:
I/We understand that if the um is too small to hold the entire cremated remains, an additional rigid container may be
used for delivery.
-OR-
An um has not yet been purchased. I/We understand that if no um is purchased or otherwise provided
(contatay iner ror Pine View Cremato will place the cremated remains in a rigid temporary
container for delivery.
The Authorization Form was provided by(funeral director name)
was executed at(funeral home name) Steve Duca
(funeral Home address) 98-07 Ascan Avenuel Fox Forest Hills NY 113 75e�Hom
as witness to its execution. and is signed by the funeral—director
INVe 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 21 st day of Aril , 20 20 .
Yadana Elumir
Typed Or Printed Name signature
110 Panatella Park T3KK4,Northwest Cal auy Can ic(
Address
21
Typed or Printed Name Signature
Address
TYPed or Printed Name
Signature
Address
WITNESS:
Steve Duca
Funeral Director Typed Or Printed Name Funeral Director Signature
14007
Registration Number
DOS-1898-f-1(Rev,01/70) Hirah F CasconName of Deceased
Page 3 of 3