Whitney, Norma C. Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: � ` �� RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY:
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
NAME: /)O �f�'1�%� �. C lr1n Qc CASE #
TYPE OF CONTAINER:
� n
PLACE OF DEATH: 3/9 i3<'c2le-�*YlUf�-�f
ESTIMATED WEIGHT OF REMAINS & CONTAINER
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION:
TIME STARTED: 1 /� 2 rf TIME COMPLETED:
PLACED IN RETORT: MOVED: 7
/T
RETORT # IN WHICH REMAINS WERE CREMATED:
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.
NOW York State
DepwWAVK of Skoft
Division of
�� t11111:�N1 t�Cit�'Tl
s ITit►TE OF �"' �} One c ff"re as Plena
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fto n for Cremation end DisposMon
This Audwha o Farm runt be caa kd*d grad NWsd prior IA dehvary Of nnaatas for CnmrA#M
8 Q2Q Number
Pine View Crematory
_*wnalwy Name:
Quelw Road,Ousermbury.NY 12804 61e-746-4477
Phone:
1 AN A"Fes.Prod.
cop ect cut by pWft the remake of the detmesed and ft cantairaer tKA&V tine remains into a ffemaWm dwrAW%t w o
i A Ito intense tees and Amos. Tha.�acrid ttaars will�ar d OPIOUare Snweyrgrdew"cepbsoas neat meth,
00do-0 ne.al that WM be laft after won.
crempftl.Owammtory VA take reamiable atorts to remove a/d the MMMM ana O#w meWied*OM#Wasm"M
taut eaM adult W dust and residue*d Mu*y be kit behkW The cren Owy wit sepwate kiddarftel and tamVn rr erW from
tta+s addte and tca.ein matst wit ba of at required by iaw• The s ww:bs waecanicsYy
Into stnMi pieces end planed rota a desowded aonNinef or um. Crud rat gerwrally we prod so
sta�rr-0gr01aeat-b racowdeable as skeletal due.
. wAW a*open to cordelrw tK kft the umcameled humen rem alm in tt rAW t#curnsta noes,such as to cwftm the
its deceased er b aruaxe that no m mtpMptoyatls of rdarrttage the . If
awnataw are degm ell in a whkh b notes tier crea>algn such as oa+emonlel er rental the
Y E 1Mlquti+a�Ilat 11N!rs its be mtreed bib# ens rrer bWGIMMOIC Filift r elk i Th*4pwft d a
or to tanslo or removal of rev o*%*0 be conducled bsf e a wdness and wit be done in privacy,with diWlty and resPeat
FAwn
tale d Oaceseed. Norma C. Whitney Mwtw Status: widow
UA10~Address: 319 BKONOWav, pout Edward, NY 12828
htaas.alDeath. 319 Broadway, Fart Edward, NY 12828
515/2020
Sex: ®M OF Age. 89 DOB: 9/7/1930 Ode d t�esth: Eats w 160
I VAN
G t� 0 C GStt lG
is wow a dvwft 0, ONE of wowkv
i arrNWs are the deeWwed agent of One deceased deed in a vA or wMw Instrument execrated pumwg to Public "
Ha llh taw Section 42t)i.
' tl"have ao knowledge the Me deceased execaed a wr(tMn metrumot pursuant to Public HOOM law Sec wn 4M or 0
d one trX the Sidon of his or her renw*w and Uwe we Me pes*s}'hav ft prtcarlty under Health UM
4�Dt and have the right tD U*Wixe�of the MffW s of ttre deoarsed. MY/Our retatlomhip to deceased 4 as
Norma C. Whitney
# *t(fir,Devi Page I d 3
#1tfQrbuftn for Cremation and Disposition
a"IFT iino
UWe wed that if the remains are not claimed within 120 days of cremation,
VMa►Crary
may dispose of the remains in
our kf*svabte manner,such as by scattering.
of fire )
um to be used as a container for the cremated remains has been purchased from Brewer Funeral Horne
as follows. Sheet bronze
UWe understend that If the um is too small to hold the entire cremated remains,an additional rigid container may be used tour delivery.
-oR-
An urn is not yet purchased. I/Wa understand that if no um is purchased or otherwise provided
Pine View Crematory
will place the cremated remains in
(Nana of CMHOO41
a rigid temporary container for delivery.
This AtrOorize8on Form was provided by Patricia Miller
urea executed at
(Funa•�Du�.aor Nana)
Brewer Funeral Home, Inc.
24 Church St.,Lake Luzeme,NY 12846 ff w'"J NOg1° J
(FunaN Nan.Adit"
and Is signed by the funeral director as witness to Its execution.
Wife have received a completed copy of this Audwdzedon Form.
The penmXs)idsrdifled below istwe the pemon(s)In contmi of disposition,who by signing this AtRbodUtion Form,atbwK*)
to the accuracy and compiabrhess of the information contained in this jkOodketion Form and auihork*&( #w forogeling.
S gned#ft 5 day of Maw ,20 20
ArthIjX itney
.d 79 First Ave., Hadley, NY 12835
Adaheas
MWTNM:
Patricia Miller
pke"Meow lyad orPWWd Nang trtiaaM Dk9OW
12466
Numbed
Norma C. Whitney
(Nan�dD�owaMe
DOS-4898-f(Rev.MIS) Page 3 of 3
77
Audwintion for Cremation and Disposition
(Insert hcxn titre list blow)
Nu mlw- 3 Description: Son
1. A person designated in writing pursuant to Public Health Law Section 4201(3),
2 The surviving spouse.
tar The wxvMV domestic partner,
3. Any surviving child eighteen years of age or older.
4. A surviving parent;
5. A surviving sibling eighteen years of age or older;
S. A law appointed guardian:
T. Any person(s)eighteeeri years of age or older enticed to share in the estate and who M/are Closest in relety A*to the "' .
8. A duty appointed fiduciary of the estate;
9. A Close friend or relative who has executed a written statement pursuant to Public Health Law Section 4201(7);
% A chief fiscal officer of a county or a public administrator appointed pursuant to the Surrogate's Court Procedure Ad.
Ilia. Any other person who is acting on behalf of the deceased and who has executed a written statement p rsuart to Public tit
Law Section 4201(7).
( ALL THREE of the Wowing) -
W#e hereby affirm that the body of the deceased does not contain a battery. pack,power cell.radioactive�+
or radioactive device and that any such materials were removed prim to the exo:iAm of this Ar dmizadenr Fe:rre. F&IM1119 606608
these hams prior to cremation may result In harm to the crematory and crarnalaq personnel.
Patricia Miller
I/We affirm that instrudions have been given to
regardlug the removal of any personal property or other thing of value which any person suing glow or any family member of the
Pine Yew Crematory
deck wishes to preserve.
tcrenrkrrrgrn.)
is not resportsible for the removal of personal items from the container or from the remains of the deceased. Personal IMMO left In Ow
conitsirwrorwith the remains wIN be destroyed by the cremation process and cannot be retrieved alter Miami.
Pine View Crematory
Me herby authorize
(Cvrnwarynkrne)
to cremate the remains of the decaaasd.
The person authorke d to receive the cremated remains of the deceased from the CrOM81017 is:
Brewer Funeral Home,Inc.
Name:
Address: Phone:
24 Church St.,Lake Luzeme,NY 12846 518-696.2744
The cremated remains of deceased will be disposed of as follows:
entombment, St. Mary's Columbadum
if for any resew the person named above does not take possession of the cremated remains.
Pine view Crematory is authorized to oft possession of
the remains to Brewer Funeral Home,Inc. by delivery
Nam mama)
in p*on or by regisWed mail.
Norma.C. Whitney
P 2 of 3
DOS-189&f(Rev.08115)