Karaka, Mary Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL RO NIE E Of RETURN TIME:DATE 6 TIME REMAINS ARRIVED AT CREMATORY: wiltO ) i011Ipy
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
(N)5 H UOJ STFndA
NAME: M614 ICAEa1CA CASED 1I1141I
TYPE OF CONTAINER: 81[{MuuT• GWk G GII*J D•M(inQ CM(iM�
PLACE OF DEATH: 31SS RaoL�—j 1A bol: 14 IM,11
ESTIMATED WEIGHT OF REMAINS a CONTAINER (Y
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION: WID/YD
TIME STARTED: . 1' 1�5�gqFlYI TIME COMPLETED: N�SAY�Ay
PLACED IN RETORT: "1T-RYI MOVED: 4• IAMN) g'D)Rn i
RETORT R IN WHICH REMAINS WERE CREMATED:
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORS THAN AS HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION m0 SRALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
NI y
Department a sum
A OF Division Ot DIVISION of Nmmnutas
OF
D"O1""" Cemeteries whinallAven,
R1J51bol
Authorization for Cremation and Disposition
TWA ArNwrhatlon Formmust Eecompleted antl signal poorto datirerydream$f"O don.
Data 061OW2020 Number lI9
crwnatory Nsme:Pine Yew Crematorium
nmre 61 Quaker Road Oueensbury NY 1281 Phohe: {518)745 77
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Crtmation le cannel out try placrp Ilre remains of Me Muratori and to drndamer holding Me remains Into a crenatbn NenM"am
Mryare outumel toidenw Mt and flame. They beat and Wmawlll lmimro end consume evarytlrlrre axwo ante and MMI.
which en all that will Ee NR older common.
Folloydn0 crernston, the transitory wll take marksman CXols W remove all d the bankers and Other mater1al Ii the aem"on
CMmber, but some minimal dust eat residue well likely be nail behind. TM GBmNdy will sepal imodental and resign materiel M1tm
"WtNito.meiWemmepwLOntoahe will lcd a$
cmeYlaw aseMtylieNulal tv
substandard n lipiasanxi material
comes or umremi tentatively anyone will
klnp0 M1egmeM de r [hgbiLO Y skeletal tluua.
OPENING OF WE CONTNNER
Tin aemamry may Dort oPon the masher house ale urveremated human remains In limited amumslance .surn Y to snRm the
Ideal the damaged or to ensure that no mktenal i0 mdoc wits might injure employees or damage me drarm yprCgM1yN
human renni an aalnmel in amMstry will Is not suitable for emmn n such as ceremonial or Asal Ye the
a story will require Met toeremains bed moved WW asu"Wo co Miner Were it aaeps the remelt. The grenlng of
mn inerm MeaansMrormmmalWremainswillbewndn beforeawi onand MIIMdonein Wivady wedlienityend Mp
NIIFCATON OF QECEggED
Name d 0meased: Mary Kareka Nmflal scow: Widowed
tall Known Address Hollow Rd., Schroon take, NY 12870
plw mf OeaM,St. Petals Hospital, 3155 Manning Blvd.. Albatry, NY 1220E
MI OM ® F Age: 97 DOB: OW411923 DmdoeMh: 081UB2o20 EennaW MN :` la-
OYcrgEon d ftwwMcadeiwrm whirl remains will beae'lvatl.
Altematrve Container Conu9ated cardboard wembet ilderier—Wand SCasket Co.
(Pononmyln 0moord AwpVwion, initial ONE draw ldbw4q)
;4'0'
are its designated agem d Me din d gnaledM 0yell re i ilpW executed pursuant W Public
w no knowledge Mat the dewY00 executed a wrillen inuoumerd pwsuard W Pi Heats Law Becdon 4201 wa
mforNe lispowenn M Ms or her renters land late am the penswl(s)III pioMy under Public HYM Law
worry
yhttoautWzede tonof"mmainsof Mele , MyMur oneMptpewdscaOY W"
rolrow
Mary Kareke
DOS 1898-I(Rev. 0MR0) Pagel 03
Authorization for Cremation and Disposition
Near rm,n Me AU ruarMr: 3 champion, Children Row Kara". Clandere Blakely
1. Apersun Montreal in warning pureuamte Public Heats law SedbM301(3j;
9, lie suarri apoum
L. lire aurvrving Momeatin peer;
]. Airy surviang child NgM14en years age or deer
A AauMWq parent'.
S. A turning siding piinful years Metre or Oder. i
B. AIeat SMOI eM gOrdinl
1. Any Mora ls)eighteen years of one or oiler entered to snare in Me estate and who same cone in ad howerap N Ma die
& A duly appointed Poll of Me wrote',
9. A Mose fend or relative who has executed a whom sideament pursuant to Public Heats lam Section 42C1l7y.
10. A Mil fisol Officer of a county or a public home nreal appointed pursuant to the Sampan a Coun Procedure Act
10s. Any,ever person we're andng Or behalf of the deceased and who has emWled a indoor federal pal 10 Pudic Neal
en 4201
(n IA HAS the blbwin9l
2I Many al thin ebey of Medesaen does not contain an ", Manor Park.pm2r eII. aerosol in nl.
ve Mev'Ice and MM a"such maMMb were removed prior to thin eaewdl of Nis AUMd Om Form Failure W raMya
N W imsYaNNbha[nwaM crsnel
a alniam Men inems have hngtwb CasM tro
n�$tIeWna�gemova M any pnmr popeM or cal tMn9 M ane which any parem rgnlag berow or any fumy menear Ones
aece.eed wishes N weaetay. Pine View Crematonum
PC
ratio led removal M personal itemshan Me cone finer ow"in tlN remains M to Mxaned. F Omi form M11n Me
tle romans e.1n be antroyed br Me cmmoi pm[na eM unnw M reWaaed an"Oriented'"
oumonuPine Yew CrematoriummIns M ere deceeaatlwbvawnori:emenamed luneel alraebrto pnaMeror Nlroxy to me aaamenm by anadman:wd necessary In Me opmm^ MiMwmraf blanche pn .mena lie roam to proalM meCOmmtn.me.na
MpMr M cmmatory.
Fill OIBPOSmON
TM personMonts to eeive the uematd rewalns W Me paramount been the wemMaryla
eame:Rose Keraka
Address: 1 Bedford Ave., ReM1Obotll Beach, DE 1N71- plan; (W2) 2A 0%
lee wemel emaina M dtteaN will MdiepcW a®wb .
Return w lemily
If for any mein the wram named repay does cot We rluwesaM aM.auMlad MMWM.
Pine View Crematorium we autnpnaM to give pmnee
ere nmeiaen RaIfbrh Nnny BtaMortl Funerel Hama _ Nobel
in pMwn or W re9latel MR. Mary Keraka r..aor
WSI S9&f(Rev. 041201 pNe2 M 0
I
Au wflon for Cremation and Disposition
ma xoa y
vN MeaWN Wl mtlw raeNrs areml dalmNaMm 120 seem of cremation,
Pine Yew Cremafodum may sapcae dare means
e vebb nnnner,auclrn bymtlYMq, m.�✓cvwp
CONFLAMETUILARIN
(rali$I CNE or the bWHy)
ReOen Denny B1aNON Funeral
M um W Ee uuE a¢a mnbinerbr Me oema�nnWna Ma Men WNraeW hwn u.....-
and is tlesaibm as forces:
I a ENat tltlro Con Nlw amallNM1dtl Me eMae vemebtl nmalnsan auum"""'e"mrrlaiM'May Muwtl Mtlel'rvery
Mu eeadi ed rT 1. NVe�eMneYM Nelnmam is wmlraseE or crossways goNeea
Pine) VIM Crematanum sill place the awned woman 0
.meo.rp
e ryrylltl Nn V aary wnleirer M tleXvery.
TINIWorbNm Faro pro+Bedby Cess'dy Van$talrna yy Qreatly al
R�Danny Stafford Funeral HomeStaf(oN Funeral Home
53 Quaker Road. Cueenabury, NY 128M
and W epMtl by Ne Nwal mrecM as address w IN eaecMon..
My nrve roFre]a Competed copy dNb aalaMaatlan Fom.
Ty pe rdayy WantlRtl Mbw sandy Na Memoirs) In control or tlbpwl cer,wM by signing arms AuldwWuntlon Form, dismiss
as Me sxwFey aW aomplMrm MNe Inlamepon cmminaE In Mls AuMwaetlm rams ant awNeMnJ My foregoing.
SapeaderN Bih lord one 20
R MAR may
m.esmre
1 Bedfortl Ave., Rehoboth Beech, DE 19911-
au� C idea Blakel
2150 Rowe) Rd. Maent B-17C Sil arawlad . NY
W11NE85: 9L
Casakly Von5tet0ru
13/09
Mary Kereka
yrwosr
wsSla96f darn, MO) PapI