Roberts, John W. Sz
Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: 6L6L_, 1C r�4 RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: �� ' -36 - 5-616LO
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
NAME: CJ 6 ko W • 7 0 � 1z� CASE # 5 2
TYPE OF CONTAINER: c16'e�aTz�71 <fAXb 1304-itl hox
PLACE OF DEATH: /J4&�v� VZd �L �{�i�-k6 0,�i677�Y`
ESTIMATED WEIGHT OF REMAINS & CONTAINER .��d �5 .!5e�,1 ,x�
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION: -LD-Lo
TIME STARTED: TIME COMPLETED: + 3�
PLACED IN RETORT: 6 pM MOVED: tt CPS1 �j'''1
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.
'4uft ization for Cremation and Disposition
£hen CMvnwm Pleas,WVft**glm Avenue
Aftny,W 12231
(SIM 4-7+e 24
www.doe.atege.rry-ue
71dt AuMarhaWw FORK nunt be mnWWed wd skald pdar to de*wy of tanwins for wermdon.
Date: V'n "f t-1� --W7 Z� Nuff6 r. 1-628
_T
Crematory Name: 1 n e U eto C-em e 4r- �� ct���►�� u rr
Addms,---2AUA-.t-"QW
CREWTION 15 AN IRREVERMBLE AND FINAL PROCESS.
Cremation is carried out by placing the remains of the deceased and the container holding the remains into a
cremmbon chamber where#hey are subjected to dense heat and Acme.The heat and flame wM incinerate and
consume everything e=ept bone and metal,which are al[that wM be left after cremation.
Following c remiatron,the crematory will take reasonable eilorts to remove all of the Perna sine and other maWnW from
the crem8tion dvKnber,but some minimal dust and residue will be left bind.The cremalory will separate
incidental and foreign material from the remains and the incidental and foreign material wd be disposed of as
required by law.The cremated remains will be mecha wily wed into small pieces and placed into a
desigivAed container or urn.Cremated mmakm generally are pulvert ed urM no singles frame is
116cogr 1 1 M as skeletal tissue:
OMG OF CONTAINER
The cxematory may only open the container holding the un-cremated human remains in limited cWclrnvAW oes, such
as to confirm the identity of the deceased or to ensure that no material is enclosed which might injure employees or
damage crematory property. If human remains are delivered in a cow which is not sviltablr;for cremation
such as a ceremonhal or rerdal casket,the crematory wS raquke that the renairm be moved k to s suitable
--AWvm befam It accepts the remakm The opening of a container or the traveler or removal of rmnales wig be
conducted behove a witness and will be done in privacy,with dignity and respect
Nana of Deceased: Z�- , L e6:S Marital Staff
Last Known Address: 1 tc- l-M _____)a &a - .t
plow of Death:
Sex: M OF Age: DLi
❑rate of Death: Estimated igl>ti
Description of caskettcontalner in rernai will be deltrereet:
Y(,t 4)00 (
OF DISPOSITION
(Person(s)in cor*ol of diwosfor�jaft ONE of the k0awkio
I aml We are the designated agent of the deceased designated in a will or written icstrurrrerrt eXeMded
pursimt to Public Hemet Law semen 4201.
-OR-
have no krKNAedge that the deceased executed a written instrument pursuant to Public Heath Law
sec#an,4 1 or a will containing damns for the d isposlion of his or her remains and pzou f rmdtee)
-1"
W&iSM-M (F ►OV10) Nam of Deoeend Page i of
I arN we are the Perscm fs)h8vm9 prnm*►Under Public Heath Law section 4201 and haw the OW to aWwrize
crenmtibn of the remaim of the deceased. NVK)ur mIlItICHISkip to the decoaaad 1s as :
flo.9ert frwr►#W ftf hWOW)
Nt"> ''. c DescxiRticrt: _SU f U I U iYNG
4-A pesur designated;
�+v
2-The � n writing pursuant to Public Health Law section 4201(a);
r�sPQUSe;
2a-The surviving domeWc pares,
3-Any sur*ft cad ekjMeen yews of age or older;
4L A survift parent
61%A suivivirg sung eWftwyeam of age c f older;
6-A IawW OPPointed Win;
7-Any peFsonfs) egtdeen lam of age or older entitled to share in the es#ate and who Was closest in
rekdkx ft to the dew;
8.A duly appointed Muciary of the estate;
9.A close friend or refaDve who has executed a wn ten statement txtrsuant to Public HMO Law§4201( y-
10-A thief fiscal otTooer of a c�ly or a pubes adn i+n OWS-tor appointed pursuutt to the suffogme�s Court }
Procedure Act;
t
'10a-Any other person who is act on beha6 of the deceased and who has exec Aed a vwMen statement
pint to Public Health Law§4201(7).
(MALL TEE of Me fdlo%*
_ UVW hereby of inr that the body of they wed does not contain a baftery.bray pack.power cell
radiOacltve imps or radioactive device and that any such mideriids were removed prior to to execution of this
Authcaizatioa Fcm Failure to refrwve theme ire Pdw to clenathm may rose*In haran to do dory and
ereanom Persogumd. r' I I
^
UY%hereby affirm that have been given to e) IN Mecft mx I 1 1� �. V, &_r Yze
regar&V the removal of any personal property or other VftQf value whim any person� y bela or any family
er memb of the deceased wishes to preserve- 6= �Mn y IMP i ek) Gv►,esFe-r,c ",e vx u Nnu F-
ia not
responsible for removal of peel Oems t the corAww or from the mvwjm of the decesu . Pew
Me us
left In t hii cofrtatner or wlth the remalns will be derstroyed by t crernation process and cannot be fe&hrn d
afeer crremat km&
f 3'
: . VWO here utflOtlZe �j OptJ ei� �e{�Y►2 Q� VQj'i�C �1U�
rem'b*m of the dkweasecL —to OwnOte,the
FINAL DROMMON
The person authorized to reoewe the cremated remiss of the deceased from the cr+eMt4uy,is:
Name:Clark Funeral Home, Inc.
Address:2104 Saw tJNI River Road,Yoddawn Heght,NY 10598
Phone: 91I-9fi2_3333
The cremated remain of deceased wN be disposed of as Bows: j tJ i. -Q (Ct U f14` --
ff for any reason the persm named above does root take pion of the cremated remains,
` y mwW r he yl e6o Cm eft M c �f'Pi'X G Uric - is awed to give Po km of the remains to
mw,wiww mno Clark Funeral Home, Inc. by dernmy In person or by regislet-ed mat
AWN Ors Page 2 of 3
qwm
x "WASthat if the remairtsare not qkOvied within i2o days of crenvMon
Le
Ouch as by �Y of the reme�s�� maser,
t ONE Of90
An um to be used as a contakw for the cremated rernam has been purchased f m
---- and Is desated as fQ&Nis-
VAk urldersbnd that if the urn is too srrat W hold the erftee cremated remaft, an adMordd r%d contakw may be
treed for
derr
-ORL
An has notyet been e _ Me understand that 9 no um is �or oft*wipFovWed
_ i Yn-e View Ce Yue 'fie iy (✓(' fiU v wilt plow the cremated Mn8kW in a rigid temporary
txtrttairter for del very.
This Authormation Form was provided by mar„ W I CGti J k-a P1�r w-
was executed at fog mwwa Clark Funeral dome Inc.
t 7-10 JOW tuLa n� r�r D(k-{7k�� /V`i and is steed by the Uwal
as witnew to its execution, f
have receNed a carried copy of oft Ac#wrizatmn Form.
The pecsan(s)iderdified below bi a tote person(s)ki eorMal of disposWon,who by sknbg
AeehoriaatfQrt Form,aft(t)to the accuracy and comp 1 NO, 9 of the irtma#ion corAmirad in thft
Ada Form and ads}the ftwegoing
Signed rids day of f c 1 Au
Typedare s
alo
ACIPOSS
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tar Typed aA�t Akrr�a Fr�e�ef
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