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Brin, Marisa Pine View Cemetery & Crematorium Quaker Road Queensbury, NY 12804 (518) 745-4477 or (518) 745-4476 FUNERAL HOME: Ci0 e_ RETURN TIME: DATE & TIME REMAINS ARRIVED AT CREMATORY: 6•5 2c) C I. NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS: NAME: CASE TYPE OF CONTAINER: n �- � p PLACE OF DEATH: _ 255`f �� -°-� _ `� Boa / 2 i 3 ESTIMATED WEIGHT OF REMAINS & CONTAINER_.-__-_2 zS 313 bs PLACED IN HOLD: PLACED IN REFRIGERATION: DATE OF CREMATION: 110 TIME STARTED: .__ T_�iTIME COMPLETED: /b - 30 PLACED IN RETORT: MOVED: �0 TIMM 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. May05M.03=p p.1 L. AWxwtZation ibr CitBt'!m t n and&WosWm o cro an.�bnMe�aroa�Wa AbMM.Mf'12231 Tthk Re mud 6e core~&WaApndpdorft dWhoop of-a Ms ftrcrmsftL Dafte -6191 aoao Number ber: crantawy MwM Pifta vim Craenamri<sm M&nw 21 tludcor Fad 9!jo�,MY 12504 Phorw.518-746-4476 CREMATION 18 AM®eRE VERSNILE AND FINAL PROCESS. Gmna*m Is carried out by pbft the remairts of thaadeceaeed and the a x toka holding the rerrrairw onto a crensdon danrberwttane they aresubiecied to i dwe neat and tome.The awaaad ftmwttt tadnarW and conetoome everything=*opt bone and maK vdftb anal tW wM be k0 diar aromsOm Folowft cr+anwtion.ate aorratay wO tMa rsamudit Worts to rwromm all of the renidm and other malwW from the crernation dwidm,twt some miranat dust and residue wN Mealy be I*boWnd.The aen oaxy wn sepwate kCkkWMWWRxviWt notarial hosts aw rerravira and the irwkka d and tur dgn ertoartat wM bo dsposed of as regt*Sd by Now.The aemobd remains vA be msd *mly pukwbed inn snail pieoes and ph oed brio a wed contairar or urm unseated Seamy are puW wlaad soW no stle Try is rsoognizabie as skdo td Gomm The crematory moot'►only open the coat wm hoMe the unoawn led human revvmbts in Fruited ch 1, a l ancee, such as to ca dkit,the iderodty of the deceased or to ensure that no rrtetoariai is endowed wilds might swooyaew or Properly.S hum=r+ei mdm are deRvared in a contdnw which Is not suhtabie for aroreatton such as a ewwftn ai or nrttd en hat the crew MM vA t up"t hd the rernWl a be ntoov into a suttabie calfthm r betas it a©coM the nwuhm The open ft of a eo make or the frontier or remmW of remains wR be corrductsd bOm a wdness and wM be done in privacy.wbh dignity artd reape& tvame aE oeosased: M/�R l SA R 1 N stag_ Last Kmmn Address: 964 ROCNE s TC-R. A JiF— g o4"t4_ b�Y \ i a i 3 Ptaoe of Dsaft 015 f-OCIA (L AVF, KLYK LY I&L Sec O>M A�rtt _ tDt3� lc�-a t9 h�, tDate of 1]satl�c �( -t -aoa� Eadrnated Vlkyt a" Ibs Desatptiott of r,onlaUca fthm in wtrich mobs wM be deed: Altxnar "Caeai w CKJO&A4b r WC.00 (ftwr"in oonrot of po*M ft k)Wi CM of#W I&ft&iao 1 ant Wb are the d sd agsnt.of this deceased drooled in a vA or written MMorA rrt exeaded Pumu"too PubNc kieotdt Law aedion 4M. -Off waft"no bwwiwd®e that the deceased on="a wrift indrtunent pursuant to Putalia tieaNtt Law sedion 4M or a wR corriairtinp ftamin m i far the dispoeib Pin of hie or her r+eme m and tc=ft ew mwp%w C` AV GA RA i`t DMIONQ Ow"no) N~OFDONSud PSM I Gra May 05 20,03:33p P 2 i am/we are the Person(s)hawng pnordy under Pubic Health Law section 4201 and have the dght to autlwrize CNer1talio!of the imimb of the A m c v me i . Mynhrr rekdonshlp to the deceased Is as folwas: (Insert first the list below) Number: 3 : DA\_)r 1.A person desigrWed in writing ant to Public Health Law section 4201(3); 2.The survwirg spouse; 2s.The scsvW tg domestic pa low. &Any su vift dM aWdeen years of age or older; 4.A survMng pwwk 5.A surviving sWM Wteen Years of age or older, �.A WM*appWW 0 : 7 AM person(s) eighteen 1ears of age or older a W&W tO share in ttna ewe and who Wave dosed in MIsSonship to the deceased; &A duly appointed Muciary of the estate; a A close friend or reft6ve who has exec Aed a wriften stattment pursuett to Public Health Law§4201(T); 10.A cdnief fscel officer of a county or a public acimirist trx appointed pursuant to the S'urmgde%Court Procedure Act; 10a.Any other person who is acting on behalf of the deceased and aft has evaded a written atabmm t pursuant to Pubic h Law§4201(n. (gel ALL THREE of the foMwA#nW _._.K}_fella hereby affirm that the body of the deceased does not contain a beitery,battery pm*.power cal. radioactive brtp sM or radioactive device and that any such materiels we removed prior to the wacud=of this AuRvorZation Form. Fall am to remove these Jim -a pricy%crsma Wn many roentt lot harm to"aronstm and Cr@rrratloy peraonnei. _, KA -tMle Weby sftrrn that instructions have been given to tsmw&=wrnwm) kec4k-TR kopoc> re ng the removal of any personal property or other ttdng of value whit h any person sqWrV below or eN family member of the deceased to preserve. Mommogn.W Fine View Cremoftium is no# reLsperosibie for removal of personal Items from the contairner or from the remains of the deceased- Petsonai Items MR in the container or wNh the remaim will be desb+oyed by On eronation process and commt be retrieved after a0rnagow tac Uft eby wAvoriae(cry mwy nwW, Pe Vies►CaremsWum to cremate the remains of the deceased. FINAL DOPCMKFM The person authorized to receive the crenated remains of the deceased from the aemalory is: Name:__Kr.,ysT.m,, Hop ktms Addrew: a�y ROc sr�►2 hVC BKt,'t �N Y l l Z l 3 Phone; y 7 L i� - ��3`1 The cremates remoins of deceased vA be disposed of as folow .. kexu1u —to F&14 i`Y R for any reason the person named above does not We possession of"cremated remains, ^� (may now) Pine View Crenatonum is authorized to give possession of the rend to mn who -ninny 4001); Et)E�kA L 9E U1 CL9, INC by deftwy in person or by r+egWWW rivi. cos-lae-H PWv.oIn0) Pad.z of3 May 05 20,03.33p p.3 Mod the fallowing) /-�R _Uft understand IW If the Mnai is we not dated WNW 120 dWp of C ematiM la I onynan ? Pme View Crenv*wiwn may dispose of the renwkis in an inr Wwwabte atamer, such as by scants". aaft ONE of Ow loeow&W An tun to be trees os a containerfor the c eahabsd wentabhs has been purdwoed*cm and is described as follows: life understand tto&if the urn Is too small to hold the entire amded rw whi%an addiond dqW=Mw may be used for detvwy- ,_ An um has not yet been pmtaaed. WVe cmderatwtd that if no um is pur dwaed or otherwise p vvided (aan�a'r+wns) Pine View Cremaborium will place the cremated r muft in a rigid temporary cartw er to delivery. Ttas Authoriradcm Form was provided by pawwoocarawno ,��r"c L�ICi�T ROOD VMS exeaded at(&wweorwn&mq I-OQD S V' C MM"h=wad*=O " O k QLTKLcq U R- tAy I IA OS and is sipped by to Iturn rsa director as wibness to fs examitiort. INVe have recWw d a e mplebed copy of ttth Ac>ttu ka ft,Form. The persor4o)idwhtllied below blue the pwoon(s)In control of deposition,who by signfg Vft Authorizatlon Form,att+eat(s)to the atxuracy and completerhess of the hftn nation oontolned In this Authorhatbn Form and uAxwiae(s)the foregoing. $igoed this 5=� day of I` N't 20 20 Key Sr!4t-- H0Q(4t4s ;1:. , AddAW T*@dorAWftm TYW*rA%bd Addrm VWTIEss: I�*4En� 1 � ,�r �o Mon Diedwsbnahm 110-1 Rolm Waft in C"t.NCL C DOS-1808-; titer.OU10} Mann of Did PMW 3 at 3