Trackey, Adrienne Pine View Cemetery 8 Crematorium
Quaker Road
Queensburyl NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: _ -giNaea RETURN
I TIME:
DATE S TIME REMAINS ARRIVED AT CREMATORY: Y/RIm IZ•De
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
K9f ix�'-Lagr�
NAME: kgeZULIf TRALKE1 CARE S �1Y
TYPE OF CONTAINER 115yVrdJ Mu1..Mn ILArcYW�
PLACE OF DEATW 23 Iftk epAt) 1 LJevory M9 Ina
ESTIMATED WEIGHT OF REMAINS E CONTAINER )SO lie
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION: 4111m
TIME STARTED: I'PD Pn TIME COMPLETED: 3p1N� ell ....
PLACED IN RETORT: : ^ Ph MOUSER
LDS T 1 2,60M
RETORT A I N WH ICH REMAI HE WERE CREMATED:
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN AE HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE:THE CREMATION LOG SHALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
TEWVOBI( Division of °NmOHOPCmmErePISa
STATEOF ne Commerte Plma
OM01111 . Cemeteries eevy,myAll Ywnnve^ue 122311
vmw.Wzrogw
Authorization for Cremation and Disposition
This AuuwrUaO'on Form must be comPIe d and algnetl Prlorto Mlivary of remains for cm "W.
Dow:6/6/2020 Number:
crematory Name: Pine View Crematory
Qu mRead Oueensbury.MY 128U 518-]OSMT
Mdree9: %pre:
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Crema4on Is came am by pacing Me remains of the demised and Me eoMainer holding Me remairsq a eemato^�8n stan and d
May are sugeded to inlmThey M me se hear and flame. They Sam will indne ands mumeewry rrg OXMO
which am all tanwhll be left after mNnatian.
Fo meng cremation, the crematory will take reasonable efforts to rmi all of the rennal and other material M1 the vemMon
chamber, bN some minimal dust and residue bell likely ne left behind The crematory will separate lnudentel and foreign maledalfrom
IN marine and the incidental and foreign material AN be hapoweignal remuked bylaw The cremated remark will IN madmically
purverizymmad smal peas and pleml into a deagnaled common or um. Cremated remains generally am Wlvadmd undlan
single f ragmand is magazine we skelmtl Xw W.
OPENING OF THE CONTAINER
The crematory may only open the consumer holding the merchandise human remains M beaded Grtumsiana4 an& as to confirm the
Identity of the Meant or to ensure that no maknel is endorsed which bell employees or damage Me crematory property. If
human remains am delivered in a Cenlalnerwhich Is notsuitlMa forcrematlon such as amnonial Or renbl Wks(the
mnawq will require Mal remains W moved Irrto a eullable wMllnmbefore IleccepN Ma Names. The Ormirld of a
container or the transfer NY renmBlIX remains wfll be demanded bebre a"M and will be done in pnvack with dignity and respvY.
IDENTIFICATION OF DECEASED Marled
Name Of Mv' aced: Addenlle Trackey Mm1H151 s:
23 York Rd., Corinth, NY 12822
tad Mnown Address:
residence
Place of Death:
Sea: OM OF Agar Doe: 5YN1837 DMdDmM:6/3/2D20 Estlmecea ight150
Deaonflon a W"UX tom in wNtl1 remans AN IN Nahanni
Basic McDonald Cremation Container; no interior; cardboard
N NCONTROL OFDSPOS N
(Gersm(s1 m aaMawS prxn, wake ONE men makiry)
I arrvWe am the designated agent of Me decreased d"gna�in a AN or written imbumem assorts] pursuant to PuaiC
Health law saetian Q01.
INJe her
No for
Mat the deceased executed a wed it mare pureuam of Pudic Realm law Sectiona2Nl as
ring dbalione for me distant on a his or trey remains and led are Me persomed final sway under Public Health law
Season Mind and have the right W allome honest of the heard m of the de . WhOur reiatiamhiP No Me d 2OW la es
fai m,
Adrienne Trackey
Dos-1Bg8-t(Main 08115) Page l of
Authorization for Cremation and Disposition
(MgzfNre Immwdrro
ewwNAk undemrarm dmt 9 Me demand am not demand wiMm 120 days a aemeean,
crematory
may dispose of Me remains in
an�nelnaabk manner, such as by uadadrM.
CREMATION LONTAINERIIIRN
M'yg(ONE of foe fdbwire)
An um to Es weal as a romaaer her Me oemaM member has own Purchased ban
and is deachbad as fdlpwa-
iNh undemrend thin if Me um N Im emal IS held the mere awarded mnWna, an manmel held consider may he used fordMlrery.
An dmrewlyN purameed. core dmmaMnd MMRm dmamrmiaaedofelnemMe mo.we
aw cmmeMry
well place be memamd rewne In
a rigid Ie mmg mnlansr kr MFaery.
This Autlrorhe4on Form was amended lay Patricia Miller was enmeshed IS
Brewer Funeral Home, Inc.
24 Church St, Lakes Luzame, NY 12 Irv.avxo..x w
and is agned by Me Nneral arepor as adrn¢¢is ad eaecu8an d
INue ha we seemed a compared copy of Mis AuMmzadm Form.
The pemonP)identified below eased Me pamoMe)in control of dlsposMon,who by signing ode AUMoftraaon Fear awegs)
tithe xaumry and compiabrreu of Me homemade conhhred In MIS AUofha Fond and suMonzela)Me fwechbi.
Signed Mich day a6 ,m 20
A� r�cl�tJnrrJ ..e�s��l�
fit, 1?ir1j5RKmm� M/ 11779
Pater5e afi
Pe4k Mllkr `'T)
Twwmnrm nsml Mvsmwaywv
13495
Adrienne Trackey
Iraewasw
DOS-1898I.W15) Peg3d3