Jackson, Andrew Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: l 60S5 rg- _—_ RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: 5 -,q-z0
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
-Av� V i x-U '
�
NAME: CGt � �2��y, C--- AS E #
TYPE OF CONTAINER:
PLACE OF DEATH:
ESTIMATED WEIGHT OF REMAINS & CONTAINER-______ rFsS,U,-S
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION: �5-- 9--zv
TIME STARTED: ._ `7!5j5- ,pn TIME COMPLETED: liD
PLACED IN RETORT: 775S,Frvl MOVED:
RETORT # IN WHICH REMAINS WERE CREMATED: _Str. �?r ®�JtI�en,,le, „l
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.
WlayO52o.0323p 0.1 E6,�5
AuUmmizabon for Cremadon and MPOGMbn o c
This A--- M-0 -Jim Fbnn aNtst ba ooaW/atad and sbw d pridor m d ffVGIlr of f or crrm -O R I
Daw9 ao ao NUmber: �
Crematory Now Pfis View Craftwha iwn
Addrew 21 iluaioor Rd q.NY 12804 Phones 518-746 4476
CREMATION 18 AN NVIE MRSMILE AM RNAL PROCESS.
CmrMw is carried out by gaging the remake of the decaaed and to co MOM holIfg the rarnai Irma s
cremation dwnberwhere VW areurbjecied io i dense heat and No 1 The haatand IduwewM iAdrarIts and
coca wne evarytlting swept bone and maN,which are eA IM will be iaf t dier GnMM tion.
FokmdrV ararnaft,the asrrwaory will tuft reasoramla eft to remoMe ail of"rarrnits andadwMaterfelftm
the c razreliar dmanr w but mmw n*inm i dust and residue wN Neely bo Celt;behind.The c mmmtory wMl sepaasW
kwidentelandfmiftn mol a i *wn fa enrait andtheindle I larx1favelpn naaarisl will be disposed of as
required bylaw.The crenuded r saWk s will be mectanic*puWerlme I irda snail pieces and placed kdo a
domed container or um.Commul ed remains genaralli are pubertal-
as shddd team
Q QE QCNIT,
The c ronalory nay only open the aoraer hoWg the un-cramaked human r+ervu6 in died ch u -ala-w e 1, such
as to cadllrm the idarAy of the decessed ar to ensun hart no material is enclosed which udgtrt" errrpioyees or
Iamage rxamaiory property.5 h%unse remains are delivered In a contoilner which Is not sul able for areawrdon
such as a eererrwnbd or tentall caehet,the crematory vA requke,that the nwns o be naval into a suitable
container before llt accepts the reroakuL The opening of a oontalw of the ha eft or www Arai of ranarjrss wE be
condtxssd before a witness and will be dare in privewy.wbh dgnty and respect:
Name of Deceased: Am l)mA SAcKSOt,� Matbei 1 2Qii�
LAM Known kidiew i�33 PQ�S►�i�t" SZ-�r
Place of Oealtr:
SW OM AWJ oo&3 - I q y I oeoe d l]sa�c W�i"3--.Z0,W Esirnaied wlaight I85 los
Descxip8ar of f%adm fCorftbm in winch ranais,wN be ddk wed:
atiWM&A Contebw c4kpeoptt p -uxacP
(Fe aoa N in c a of dirpaeN i L J@M ONE of Me faluvi W
!aml We are the dseignehed agent of the deces oul meted in a wi or written Inettu ant examded
purstarrt to Public dealt Law sect!a w 4201.
MLtnl�e two no lowndedpe that the deceased errecul ad a wrOm Instwnei t pursuerd to Public I MA t.aw
4201 a a vA oordakft diecdons ft the diapoeition of his or her remons and fDaa*wwm*pm*
AwotA--,,A ��tSbb-1
DOS-ING4 r mar.OM) �dD�arod Parts 1 of 3
May 05 20.03.33p
p.2
l aml ws are the psraon(s)having pricy undw Public Heath Law section 4201 and how the rigtrt th authorize
crematbn of the retrains ofthe deceased. MylOur whip to the dOCUAW is as foNows:
(k ed fi m the fiat below)
Number: ), Description: RuSgAklb _
1.A person designated in pursuant to Public Health law secltion 4201(3);
1 The surviving spotae;
2a.The scuviv f danestic pa deer;
3.Any suiiving cad oWdeen Years of age or older;
4.A survivirb paned
&A surviving MIAV yeare of OSP or older. .
6.A WM*aPPMed OUNdiMr.
7 Any penwKs) eighkm yeam of age or oast wv A W to shams in the1 1a and who isf m closest in
relatlorsliip to the deceased;
&A duly appointed Rducimy of the estate;
a A does friend or relative who has executed a wriKen statemm t pursuant to Pubic Health law§4201(7);
10.A chief fiscal officer of a county or a pubic adn>ir istraft appoifed ptatsaant to the Surmp t %Court
Procedure Act
10a.Any other person who is acting on behalf of the deceased and*fto has eoremd ed a wrillen stakewd
pursuant do Pubic HeaNh Law S4201(7).
Taaft ALL THRM of the f ftm*W
7 -1fYlfe hereby affirm Wt the body of the deceased does not contain a battery.battery pack,pmw Cell.
hri Awk or raftective device and that any such maw wane removed prior to the execution of the
Authorization Fort. Fal as to rang a Ume ll erns prior to erematlon may resat th trmm tot*eremstory and
Cr6ntaUMMY personrmi.
CA WW hereby affirm that instructions have been givers to momadiscfornon* 4 l+oo
the removal of any personal ply or other thing of value which any personisigning below or aM y
rrrerr of the deemed vrishes to preserve. mmmoo-- l Paine View Crematorium is not
responsible for removal of personal hemsfrom the container or from the remains of the deceased. Personal items
left In the ewer or vdh the remains will be destroyed by the won process and cannot be reftwed
arfber c envalk ra.
�2_V409 hereby aallorize(aMIory MMQ Pyre View Crematorium Ito cremabs tie
rains of the detssssd.
FINAL OLIPOSITKNI
The person atdhorized to receive the cxemated remains of the deceased from the crematory is:
Name: EVvl 2`/ :',/kCksbht
Address: 13,33 P e_c s i oCj4-r ST(Z.C.E r (�kLYc-F r r*Y W2,13 Phone: t 3 l_ 5-31
The canrtated r n*m of deceased vA be deposed of as follow.
RluUet�'( T-6 E5:kA t-Y
If for any reason the person named above does not We possession of the cs+emated remains,
(M MAMob RUM) Pins View Cromalcxrum is authorized to ghrs poseession of the rwr"to
&nWW Ij- M MWW) by deivety in petsm or by relgelm,ed ma.
ANON '5A(-' K3o(A
omiaee- i raf.oin% NM*GFDS Mnd Pap 2of3
May 05 20,03:33p P.3
Oaft the btraw
E� UM under:d M IMR If the rlernains are W cdainted wbhin 120 days of aemafti.
Fine View CrWfWAorititn may dhgxm of the remains in an irr blevabie mammon,
such as by sc etterl. .
(jam ONE of do ftft &W
An um b be used sea e ontainerfor the crenMa rf reamb tms been punchased tram
and Is described as follows:
UWe understand that if the urn is too small to hold the enure awnsied mmi IS,an addiwW dgM cOtMtf:T may be
used for do"-
-OR
C` An um furs not yet bean pur dmsed. Me mdendand that if no um is purchased or oftn me pmvided
Pine View Crematorium will place the cremated rem**in a rigid Uwgx racy
coalmen for delivery.
This Authorization Form was provided by @mwwerwcyarxwnN kia4k,r--:_rl-4 WOOD
was executed at(h , arhommmw. 4COD FtJLaF-aAk- Sl Ytvt Qzx Zi(c-
t eadr wo AWL Ptr t<.IL+t AOa- 114 r 10,01 and is signed by the Uwal dkedor
as witness to its exacution.
INVe have received a completed copy of this Authorization Form.
The person(s)iderdffed below is►m the person(s)in control of disposbion,who by&%p mg this
Aut horhm*m Form,attest(s)to the accuracy and c a- 1 ton 81 a of the iMonnation contained In this
Authorization Form and aut wrb*sj the foregolM
Signed V is S tit day of MAY 20 20
,Mo2Y a.4cKsoc u�"^"
Typd or F%'-*d Abm Sipnalr+�
1333 Mzsunt cr s r. 4�Lw4
AMW
7ypsdorArinNd htaais
AcOm
WRNESS:
kEut a-it-
�rra�fa eft 7WwdarPM*dJftw r ,.rc�r.ce►sr�,.fr..
/kN09-CA 7 C-VSOt4
DMI Qom►.O"CO Peas 3 of 3