Hicks, Pamela Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: -40'a5 RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: 5'9•-Z.0 C �`.--S_
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
_nuu�
NAME: _!_�ityl IG�$. _ CASE # 570
TYPE OF CONTAINER: &A CdrGya_4,Q
PLACE OF DEATH: nix;
ESTIMATED WEIGHT OF REMAINS & CONTAINER C 7SItM
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION:
L
TIME STARTED: ._ � _.TIME COMPLETED:
PLACED IN RETORT: _ �- MOVED: AL
U - - 3
RETORT # IN WHICH REMAINS WERE CREMATED: _ uWv-,.,L AK 4
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.
May0520.OWft A.1
mmummumdofWAft
Aut wkabm for Cmmatmn and UspOsitiOn omdoodcommWin
inscomwomtvoaa,00 Iwa m
cs��nr
Thbs AuMlioe�las o Foom Oust to corMi MWod&W abm d pdw to d hosoy of a& m ftr cr m tL
Datm 51 oil �,10 N tffd .
Cre nowy Nsom tine hies Cramat nkan
Addmss:21 Quarter Rd QuawWxvy.NY 12904 Phone:518-7464476
CREMATM IS AN WJM VM SMLE AND RNAL PROM
Cremation is carried out by plachV the mltairts of the clamed and the cortiairtm ttoi tg Ste rwrrains trite o
aamdbn daamberwhm a they a m subjecied io inierree heat and t onmL The Ina and ftm wM indneawie and
tmrwuna ovoytldiggg m000pt bona acid n tak which are all that vA be left atisr animation.
I:olowk p arenaMio %the anrnaiory wN tnlm r+emwoubts aabrts to rsrra m sN of the renrabts and other r womiai thorn
the creettetion dur dw,bud earns n*ri nd dust and reslMas wN holy be left behind.Ths crenmmry w1l sepectite
1 ciclmi tol and iori ft nr min riet tram to renwins and this it cidwrtei anti taeign aisrisi wM be disposed of as
re*drod by low.The cren sled rannirts v A be mectwdc*pc*vwked irrt wnaN pieces aril piaoad kft a
coed container or un.Cnraatad naadm generally ass puivaartaad umW no single beg nwrt is
reccomb as 1
QEBMQE
Ttw ►raay"oPon ttw container twWm the u-am abed hu m remains in knftd circunret m e m, such
as 10 oordinrt the identity of the deceased or l o ensue that no material is ermlosed which might Mjure errrpoyaes
ol cmmimy pit S humom cwnales are delivered Ina c ontsdrrar vA"is not suit" evemation
such as a cme nwnbd or rental cooks%the usom Cory vdN n p*o that"ewnWm be. tnto a suftabla
conhinar belbra R ate the ram.The openbg of a vontoirw ar the fjumft or rerrto N of imnsh wN be
candttctad before a wid wn and wN be done In privacy,wih cip ft and respect,
Name of Dsoessed: P Pt A E A 1-(C K S I M M I el Status: ! R-i Ic.D
last Known►Addmv&-_>U l5 G LeN w ocay. b" SKL`t it E t4 4 i I a
Place of Deattc L IT. S t(`(A i �b5gj Vu, (W."Cyt'e)
Sex Ora EfF Aft j3 DOS Dais of Dlm tr 4 -%- ;k o zd EWnrsied vlf t Ibs
Desc46on of twsltatticoralainer in which remafio wM be dollumed:
AIt fMe t�n>alewr �C4tW(3 0!42 p + w o OD)
(PbraWIN it S'0- a I ofdiepoeitara 10ft OW of ltw MbWA rwl
1 aml 1Nb are the desiprsaiotd aysrt.of ttis deceased dosipeisd in a wi or wftn kott want emoL ted
PUMMmut to PLO@ i Law section 42M.
-Old
_W W40 nays no kwwiadge the the deceased eve And a miAsKt WmVumm�t pursue d to Public Law
sec&m___M or a wN oonbkrirtp dinsdiorts for the dimpnddonof his or her mnlwm and gbw=etr nwpaoy
QAKCQI- 14(CqA<S
008-low" fir.MG) AbW oromom"d POM i GM
J
May 05 20,o3.33p P 2
l WV ae we the Person(s)having pnoriEti under Pubic Health Law section 4201 and have the right to atdtwrke
c:remaWn of the renarins of to dscesesd. W yMur relationship to the deceased is as foNows:
(kMd from the Rd below)
Number:_ Deso"lon: (;Oa(
1.A Person designated in pc to Public Health Law section 4201(3);
2.The surviving spouse;
20.The surviving domestic parbw.
3.Arty="q did eWsen bears of age or older;
4L A surviving psi
&A surviving sibling sytthreen years of no or older.
&A r 8PPW ed QUa d W:
7 AM pem«K$) eWdwn tam of age or older erMed to shads in the earl 1 P and who islem dossat in
MWWS*tp the deceased;
&A dull appointed kluciary of the estsba;
a A nose mend or reft ive who has executed a written statement pursuent to Public Health Law§4201(7);
10.A chief fiscal officer of a county or a public adtr or appointed pursuant to the&Kmgabe%Court
Procedure Act
10a.Any other person who is adlrhg on behalf of the deceased and aft has wed a written statsrnent
pursuant to Public Heath Law"MI(7).
(&Wd ALL THREE of Me ftbwkW
_UInks hereby affrrm that the body of the deceased does not contain a battery,battery pads,poaw call,
radioactive bnplamt or radioactive device amd that any such materials were removed prior to the OXOMA an of#M
Au on Form_ Folhae to rersove those tarns prior to arematon may reehdt th harm to the crewd*m and
crennalJory personnel.
_91 -Uft thereby s nm that instructions have been gmen to ta•,maadrsdorMmq Ktw,te rtk [40W
regarding the removal of any personal property or other thing of value iftich any person Signing below or any fW*
member of the deceased wisthes to preserve. (r mm"ynnmq Pine View Crematorium is not
n"pansible for removal of personal Items from the gainer or from the remains of the dam. Personal items
kdt In the container or with the rernaiem wAN be desb oV od by the cremation process and cannot be moved
otter crarnartlorh.
IMft hereby audwin&MMO rynWW' Pine View Caremstwium to cram the
fd"ns of the deceased.
FINAL DUNN)SFTION
The person aul harbad to receive the crenated remains of the deceased from the crematory is:
Name: M t ct+kC-.L Tl#cxKAs
Address: 611( -)pZiE Aug G Lgt DALty , 14-Y 113 8 S Pha<he: C3�7> a - 71
The cremated remains of deceased v Al be disposed of as folmm
if for any reason the person named above does not take potion of the cremated remains.
(—womm n m.) Pine View Crematorium is authorized to give possession of the remains to
(knows memewty IOW :FQW C-iA-- St=._LV t U�S, zi-tc by detivety in parson or by registered ma#.
ws.iawu ouv.ono) Paps 2 of
May 05 20,03:33p p.3
{fir the foiMowir�
LN%undSMUM Va If go rylns are fW c lakyW wjM 120 cars oft,
(a.wb,►m_l Pbre view C Knatortum may dispose of the remains in an inabievable mmnner,
such as by Grp.
tl cNEofma"Ow*w
An um io be used as a canh iner for the a�emamd rema has been pardused from
and is described as follows:
IMb understand that if the urn is too small to hold the"It amnatsd ram,an =ftkW may be
used for dekmy-
-OR-
PtT An um has not yet been pmhased. Mb tmdersthnd that if no um is pmhwnd or alhemise provided
lasmefo�►+wm) Pine View Crematorium wM Place the awnaied remalm In a rigid temporary
coitakeribrddimy.
Ttft Authorization Fbrm wes provided by p nowomewmw,) j<Ckt .r,_rt* t+cs o%>
was executed at(rbasraNymmmum, lfmo tut-kc- AJ,,
MnsrW hOM OMAN* lci O t ���c 4 A-u�- (�(4 i4 i 4 q t r dZS and is sued by the Am mat drOdw
as witness to its exec tibm
IMke have received a completed Dopy of this Autharization Form.
The parson(s)WmAlled below is/m+e the person(*)In control of disposition,who b7 signing this
Authorization Form,aRtest(s)1b the&=Wwy adrd Col.plebsrre I of the inIbinnation conla fined in this
Authorization Form and authorizes)the foregoing.
Signed thish-rr+ _
dory of 1''lh
M( AAct- Tt-vo tK,4,.:
rypsdGa F _1 1
(v`I I S 7o 44 d E LYct N 1
ypetf or Sgr,�a.1►
Addm
rWWQrF%ftdlft m s
Ad*m
WITNESS:
Fame+C&*dw 7jwd or Paalsd Jftw
albs t
Agiel iota f�er
Pate=�a� 1=�jck s
aos-IeWu tR*v.0tn0} Acmeorpommd P803cf3