Lape,Edward Pine View Cemetery g Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 Or (Sig) 745-4476
FUNERAL HOME;
(G/ iwymr_ __ _ _ RETURN TIME:
BATE & TIME REMAINS ARRIVED AT CREMATORY:
NAME OF FUNERAL DIRECTOR OR REGRISTEREO RESIDENT DELIVERING REMAINS.
NAME.
TYPE OF CONTAINER:
ER: � _ - ({i(�_/ /�
PLACE OF DEATH: -+w i Low -
ESTIMATED wElcgr '—'-"------_.OF REMAINS G CONTAINER_
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION:
TIME STARTED; . 71
TIME COMPLETED:
PLACED IN RETORT:
-_ _..__—MOVED: _ J
RETORT p IN WHICH ��'--�--REMAINS WERE CREMATED;
DETAILED REASON FOR DELAY IF aq • _" -'REMAINS WERE CREMATED MORE THAN AS HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SHALL BE RETAINED IN THE IERMpHFxi FILE Or THE CREMATORY.
anon
KATEOF Division Of ONMIO NOF rvEMETERng16
O%OP11N"" Cemeteries D m ry
Tasmma.t5814APal
Authorization for Cremation and Disposition
This Authommacn Form must be computed and signed all aelHery anmalm/foorr an uaaon.
lotto O6A)4QG20 Number 7v (
Cremabry,Name: Pine Max crem
Mdms: 21 (aaMr Road,Greenaway,NY tISW Mom. (518) 745NI
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Comments owned am by plating the remains of the demaaM and MY mntiimr hoping tln remains into a uncommon chamber wlwre
Nayamwblec bintenseheatanddame. The hat and Game Mll Inclmnu and moral a "Ing oxepf bone antl maul,
which an all Wtwlll b MRaeer cnmaon.
Following ummadon, Me uematwywiu Ways recall eXodalO rem v¢all of the remains and other material Man the must
Member,but acme minimal dust and nsam 411Iiyeh be left dNindoThe cremal will spanu iinvoil l and royal mamdel from
Ue reseal and rite mccomnl and foreign malehal AN M demand M as accused by lax. TM uemated remains rill to thrma lty
panel mbsmall piece and places Into a designated mMainer or um. Cnmaud mm ina generally an pulwdud until m
ehple Nagment Is nopnmMe as analyst bsm.
OPENING OF THE CONTAINER
The Moral may only open Me oenomer holding the uneremaed human remains In limited aumasnrea,such as to confirm the
merely M the deceased or b ensure Pat no maPonal is succeed such might Injure employees or damage He oematony gomny. If
human remains an delivered Ina comi which Is not nubble for cum rdon such As ceremonial wnnsl coal Me
cnmalo *11 require that the remains be moved into a suitable comes.authorsauthorsit accaper Me mnalns. The NAnirg Ma
nMiner or me o-anaer nr removal m rem.e.wee m ca,arcma before a wlMms area will m done in pMary,w;M agniM.m reapM.
IDENTIFICATION OF DECEASED
Name of Deceased: Edward Lpa Mami$ , Mart
Lunt Known goal B bwbn Ave., Apt 2, Glens Falb, NY 12MI
PlMO N M: Glen$ Falls Hospital, Germ Falb, NY 001
Sex: ®M OF Ape. BB wit 011D611960 DaM of Centel 0610113020 Geothermal weght�
Nachman of pekBU[Onelmr In MlN remains vall be de dmad, /
Cardeoard Box whVooden Base ( iLap
PEMN IN CONTROL OF OLSPOSn1ON
(R S)m GManty (nafi'm,Want ONE of Me fromen )
I amM1W am the dmigmud agent of Me dexaeN designated In a will or when ImbumentMude]punuant0 FomO;
NmM Lax Se don Q01.
OR-
IN✓e ham no handfudge Mat Me m nesea mend awines Instrument Wpmm to Public Health Law Section 0201 or
vdll concerning dtrtctione V Me dbmsNOn of his or Mr remains and Ind are the(Nnon(a) having pnonty under Pudic royal Law
Serf n 4201 and have the hie ronMniae cremation of the ntmma of Me dismissed WMur reeuonanlp to the det.aap Is as
Mlws:
Edward Lape
smaimmism
DOs18984(Rev. OV2M Trap Wd
Authorization for Cremation and Disposition
(InI war din pemam 1
Number 2 Oeeenpoon Dixie lepe(Sp )
1. Apersan designated In venting natural b Public Happy Law ywMMn 4201(3),
]. The surnal dearer
as. Line surcMng domestic parter'.
3. A"suMving Died eighteen"am of We or Men
A. Asymbl meant
5. A suMny surly aghlwen rears of We or olden
S. A lawblh apMilef gualn,
T. Any aments)Warer wool of age or ltler envied b Share in Ma esi and who hire abroad In ntldomfiip to Me 0eW889Q
a. A duly amounted fiduciary Of May estate:
9. Atlge 4bM or relative adw has exxWe]a wi statement Waxman to Pudlk Has" law SwMen 4201(7),
10. A OW filial oMwr of a muly or a pulk Mminislrzbr appointed pursuant W May Surrounds Coal Protalum All
Hou Mry mM1m palM who is acting m troll of day measured and who has awarded a wrltlan mammal im uom W Public Health
Law Snarl 4301(7)
added ALL THREE by Me Wernad
�It Way heradr affirm that the body of the demared does not coupon a WSery, all peck. noon tall, rllo=se lmplal
arratll0emnre tlervA BM Mal enyeuN mgnalswara ramor9tlpwbNB B+eNtim olMh Aumwhetlan Form. Fvllummmnme
Mesa tWme prlwm mametlon mry result In haver mMa cmmemry end emmabry personnel.
`v �t VNa¢deal Mat iiuhudiormnaw been 0henro Rl G. Hoag
regamirg We removal of any pmmnal mopem orober MiigotNwwhich Mywlan mgning below r.rn family momb dM
d�why to Premrm Pimevww Cbm m,y
a not responsible extra removal ofpatuone dinahon Me normalfrom me mnamsd"Ma Slaw Nmorliams NhIn Me
contalmr or with Me remains MIl be destroyed by Me crsmalbn process and cannot be reMevm vM cremvuon.
-Dd'L' mehelbyauMorire Pure Vial Cremmay
lam IMem aim of Me dawaeed.
(More OPTIONAL)
Vies Mnby aMod iM named funeral dinower to provide for role W and mmal by on abmW
vtory,If deemed necessary In Me opinion of Me funeral dlrscmr,and to amerW Mk form to pmNda Me correct name and
address W such alternate cromtory.
FMAL DISP08RION
TM pmam aW zed to relive Me cremated haul of Me b aced Man MBGemlory in
Name. Compessimme Fumml Care
Address. MR Maple Are., SmaWga Spmps, NY 12ce Made. (513)58648K
thus aW remaro of Malawi well be dg 0f as WMas'.
R NM TO FMllf
H M my harden Me Polon named Spaces Ma9 not We p ssm of the ue l 8Ms,,
PIM Vow Cmmamry a wMoiz9l He give masession of
enews,now
gmM1 imto ComWsumm FUNGI Cam, line by dtlrtwry•
in person or by We mail. EONN Lye
DOS1b81(Rev.O4120) runes Page 2d3
` Authonturtfon for Cremation and Disposition
eni vat Meaning)
IMb undersmnd that If Me mmelns are not deimed w,mn I days of intention,
Itirevlew cremaMry may dlapEB Of the memory in
an nmma.ahY manner, such as MxmnYirq.
CREMAMN
lLlllat ONE sate lWowmp)
M um I be,use] in a=Wmer M the ae A arcs naz ICBM pwoawd ftmm
and a Mandated as MI
Wk UNS9 K Mat I the am'a W amYl to IWd M mane va mssim , M additional Mid conommair may W uwd for daliuerv.
oR-
L` Mumq Mt piWaAaa 1. INNimMy nd Mm Mnoum YpuMa woMm® =,WW
Rrc Vim Cmmekry Mil place the command homes In
mea4 sn
e Met WarnWmry wants"W Mai
llib AUMaUu4on Form was pto'nmd In Rdi C. Ib; "a annotYtld
Com mSimm@ FuneN Cate,Ind
J03 Meple Pue., SareWy $qiN& NY 13May
and Y Signed by Me Nrwtl dimCM as witreaa to IY m agora m®'
II have MaKed a mmplNed cony of this AuMarYatlon Form
TM"Maine)Identilsd ONow Man in Me nommis)In control of dYpwNoo,Mao by slpai M this AulMr gm Form,Yunin
on Me accu my and cmmplMnns of Me Information ConUiM In Ms AUMwza( Form and aulhoNais)Me bmgoing.
Signed M sa Mls ° a.v of June ,3o TD
D Y UK
obi
3 LaMm Ave,Ppt E, GIms FYY,M'1S0g1
WITNESS:
RoWq G.thing
1&% me..
mr
1
ECwadue,
DGS1311bf(Ray MRO) Pape 3 of 3