Reid, Michael Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
Ll
FUNERAL HOME: _ 4 Gb 4I 1 RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: t 2�
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
NAME: /� � CASE # 56
TYPE OF CONTAINER:`
PLACE OF DEATH:
ESTIMATED WEIGHT OF REMAINS & CONTAINER---------- = 2 _
PLACED IN HOLD:
PLACED IN REFRIGERATION: - —
DATE OF CREMATION: (70
TIME STARTED: . ?' 1 l _.TIME COMPLETED:
PLACED IN RETORT: �Z MOVED:
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.
'MayO520.03:33p p.1
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Ctema W Nana Pins view Crematoriu's
A 21 Qualm Rd Cluearab",NY 12M Plow 518-7464476
CROMTM 0 M 6+lREYERSIBLE AID ANAL PROCIEW
Cremation is ceried out by plate the inm s
cn muMon dwrAw wlwne VW are subieded Is intense twat and Some.Tbsa but and tisaee vdIl iordneraII and
env enaarything erranpt bore and metal,which email that wA be left~ rai a MVWL
Folfowinp r rerne"I.the crematory wo two ressonebb afAorbe to reeve all of Ue rerrrslns and char naftrisi*OM
the aeration dumber,but some minimal dust and residue mill tilody be k*betriad.The asmANy will separate
and fiory ft msaeriMt iron the r+wrrdrw and tits buff iai and iorelgre meta N veil be dlspoeed ores
required bylaw.The cremeled tenains wi l ba rnechwftel1y pi i mla n 4 inlo►smat pieces and plaoad We
fts%p ftd container or um. r. n v Ied reamins generally are puMaiaed=0 no GINSID Dagrnwrt is
rersogni:abie as shole"tssa&
oP8a In GE SONTAU
The aemslory may only open to container hog the urvaemated hunen to vv* in Rrtilad ifences, such
as b carrtirm the ideeiflly of the deoeaeed ar b eraure that no nalerial is errcbesd whidi migtd true errrployeree or
damage crematory popes►N hainas nmudas are delivened in a wblch is not sullawie for areraatlon
such as a cerenwniat or rnrrlai cseics#,the crematoq vA n p*e tirst Ute rsendns be vew into a sAdtabie
Mew betasaft accepts the minshm The opening of a owdainerr or the transfer or removal of rernair>s vA be
c�ndrscled before a wkwas and will be dons to pdvaq.vft dignity and respw:L
sainFICATIMIGIFOECEASIM
Name of Deceased: h I C i4 A O_t-. ltI-:-t D Martel steam MA Out,r<p
Lad Known Sly �� _1 T akLycIL ►r!Ila*
Pleos of Deeitc MT, C,l iV A l 1AoS9L TtN-
Sac 6'M.'OF Apse DOD 1 r l St Date of ouft 41t51167,0 wed Vliaipht f� Vs
DssmV lion of fardoeticorrleirm in wtirch rema�s wAI be delivered:
Allen ilye Contdw
(POrsonN in Dorton of rim M I an L jdW tMEOtto IONOW&W
I arN We ar+e to mated agent.of the deceased deely,min 4 in awl or written tnstruma t executed
puma rI to PubNc Head law unction 4201.
-M
�JO Law
aedion 4201 ar avA eonbei ft direeliorrsfor fhe deposition of hie or her vemak and (0arwwwnwprert
MIC14Ae i.. jRF-iy
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P2
May 05 20,03:33p
i wW we ors Ore persons)tvra g pnorty under Pubic HImML&wmcdon420i and have the tight tD actttorize
Cemadbct of the r+emmtaims ofthe deosssed. ftftr tehionship to the deemsed is as Bows:
(hts ditmt ffm rid bobw)
NW*W._ Desaipdort: W I -
1.A person dmig -min l in writing pu muettt tD Public Health Law section 4201(3);
2 The spouse;
2s.The suuviv+ng domeeiicc pat6ner.
&AM surviving chid eipfdeen you of age or older;
4.A survIVIng parent;
&A surviving sibil aigtr6set+years of ape or older.
6.A Waf*ap *W glla ffM:
7.Any persom<s) e%ftiaen 1eag of age or older entitled to stwe in tir®estebe and who Were closest in
reladionsl*to to deceased;
8r A duty appointed tducimy of the estates:
a A close friend or relative who has executed a wrlttent sbdaim►t pursuant tD Public Health Lana§4201(7).
10.A chief fecal oifoer of a county or a pubic adinli strator Wpoudad pursuant to the&woo ts's Cart
Procedure Act
10a.Any o0w person who is acting on bdmdf of the deceased and who has executed a wd t n statement
pursuant to Pubic Hedth Law§4201(7).
(ZaM ALL THREE of Ow ibNow ha)
Vft hereby alfum that the body of the deceased doss not corttaln a battery,battery pack,power cell,
radbactive implant,or radioactive device and that any such mates is were removed prior to the execution of fhb
Authorization Fort. Faihme to remove these Ito prior to cr+emod a may tout In halm to*4 crematory and
crematory persoatneL
V 11__tMte NP*W aOinm that in0suctions trance been given to mNwalawfor wao KEb4144�—rit 14W
regarding the removal of any personal property or o0w# tg of value wldc h any person signing below or any family
rnerrtber of the deceaaed wishes to preserve. &mvmjrnwn* Pine View Crematorium is not
c espal for removal of personal hem from the container or*om the remains of the deceased. Peaoeal items
left in the contelreer or wth the remaieas vAN be destroyed by the cremabon pr ooeas end carinat be r eh ievod
aver cromahoA.
_yH �Uwe Eby wAhodw&mmomy,,,,,,y Pltre View Crematorium to cremate the
remisins of the dewaee A
FINAL DISPOSffM
The person au*Kdzed to receive the can remains of the deceased from the crematory w
Name: V ERy►,t c.n 14 A N>sL
R 1 art P4 Y i t 13110, Phan
The aemated remains of deceased wilt be disposed of as fotiows`
1 XL)kt4
If for any reason Ore person named above does not fairs possession of the cremated remains,
td,�,.i Pine View Ownst atum is authorized to give pion of the renatrw to
rye„c ,,,.may 1 Gcat7; i`il.ug (;t A't Ci0 �t+&' by ddvey in person or by egiderad irag.
hiCI FAi.L AD,
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May 05 20,03:33p p.3
OMM UMft*VA*lg)
t uvula wxWsU nd VO N to rernalne we nat caned WOM 120 days of aematim
l ►neraRl Pine View Crarnatoriurn may dispose of the remains in an irmbirvable roamer,
such as by seem".
aaft ONE ofOn1b )
r. . An u m b be used sea conW bw forth* r-o n t Aed rerrcains has bean pumhased tom
and is described as follows:
INV*undwidand that if the urn is too small to told the entice own*ed rw abis,an addltionel rW=t kw may be
used for dellmy-
-OR-
. An um has not yet bean purr ed. INVe widerstand that if no um is pmhased or of wvnse p viKI d
(cmim„y nw ) Pine View Crematorium wM place the c myMed remauss in a rind temporary
corl�tirier 1�or deil�tery.
This Authorization Form was provided by owcftrnwv*
was executed at 00wathmae F-EL)Oh FUI`iii_U Z ►2�'i C 1tC Tl�c.
tthnorw w -adavW i. ' ill T I tA L.i .A vi-, My l 1 X('f and is signed by the ft raW director
as witness to Its exacuftL
Uft have received a completed copy of this authorization Form.
The person(s)ider>tliied below ishm the person(s)in control of disposition,who by slpft t hk
Authorizatlon Form,allnt(s)to the accuracy and coinpieteness of the hdbn i Mon conodned in this
Authorization Form and autimcke(s)the forsgoing.
the day of M-Y 20
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