Grube, Anna Pine View Cemetery a Crematorium
Quaker Road
Queen3bury, NY 12804
(518) 745-4477 Or (518) 745-4476
FUNERAL HOME: _
RETURN TIME: _
DATE A TIME REMAINS ARRIVED AT CREMATORY
NAME OF FUNERAL DIRECTOR OR REGRISTEREO RESIDENT�DELIVERING REMAINS;
----__._ kArr 7gv- fLD.E.-- _ .
NAME
..
TYPE OF CONTAINER: ._CASE #hb((_�� _����_ '
PLACE OF DEATH;
goy
ESTIMATED WEIGHT OF REMAINS 6 CONTAINER ,
PLACED IN HOLD: --"-
_f
PLACED IN REFRIGERATION; Z ;Fc
DATE OF CREMATION:
TIME STARTED: -"�—
-""� COMPLETED; O
PLACED IN RETORT; ��/ -'---_�
RETORT # IN WHICH REMAINS WERE CREMATED: ~-
DETAILED REASON FOR DELAY IF �eKJ[
REMAINS WERE CREMATED MORE THAN a3 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATIONE GO SHALL DE RETAINED INTHE PERMANENT FILE OP THE CR6M4TOAT
NOW YOM Saw
PORK Division of dVIBIGNW FCEMETERIES
STATEOu O nrarwalePa
OPP
Cemeteries N
AiWy.M'12231.0001
Texchiso,'.exp4we226
Authorization for Cremation and Disposition
This ANF zanon Farm must W campleme and signed pitted owners ofnmvm for channel
Oars:6WO20 Number ll�
Cron" Name: Pine View Crematory
Ouaker Raged,pueenstal NY 1280s St&]aEit]I
AWmss: Plmn:
CREMATION M AN IRREVERSIBLE AND FINAL PROCESS.
Creaatbn isdemand our by Al Me remains of the arrested and Me conlelner adding the remains arm a cadmium Camber whom
they ere subjected to intense bear and flame. TN real and hams will InuneraN and cansume swryWrq eaceM bons and menial,
which are all ti will be IsR after cremation.
Folbtina monarch.Me amatory an11 tare mabomeble anoM1s to reco a an of remema and other material find the CremabW
member, bid seen¢minimal dust and residue all Iikely be I611 behind The chemistry will widened Inadental and breign material from
Me retains and Meimitlsntal and breist materiel will be disposes regwred bylaw. The madded remains will be memmnweYy
a0mazed into small pieces and placed into a designated mMaineror on CMnaiad remains gsnevlly am pulvedmd untildo
single fragment is recognizable as sxNWl nasus.
OPENING OF THE CONTAINER
The monetary day OMy open the container holding the to<remaW human handns in limited dnumstanras, such as to orfnrm the
laugh of the dereesN orbereum Mar no maledal is endowed which might injureempbyees or dameglMe memalory pmpedy. X
hananremainsamdeli"mdInaa inwwhimisnotauihb4brcmma6onoathseceremonulorrenal Caskek Me
codowry will require Mat Me remains by movM laid a suitable morma Whom It accepts the remains. Theopening"fie
sent or this tan"ar removal Nrenreine who be mNLmed Norman a wine rs and will be done in privacr, with dignity and respell.
IDENTIFICATION OF DECEASED
Name ofDapened'. Anna Grubs Martel Shtus', tlIVOICed
318 Main St., Corinth, NY 12822
Last row.m Address:
Place of Death The Warren Center, Gurney lane, Cueenstrury, NY 12804
Sex'. El El Age84 DOB: 5/19/1936 Demarcation'.6 p Scandal waughL 250
Description of®skaationa men N whkA remains art be delHared.
MacDonald Cremation container; basic with wood inserts
x xcoNWni OF DISPo81TON
(Perm+is)d amlM or cludgmbm Coll ONE of Me MbwMl
I anN4e are the designated aging of Me dxeseM designated in a will or crown Instrument wedded pursuant to Public
Hei Itw Sation 4201.
-OR--
Q6— IM/e have no knowledge that the deressM located a wheat inmrumant pursuant to Public Heats Law sound each or
was owdm mrq diremwns for the dispwitim of his or her remains and Am are the Personal havbq priority under Pubic HeeM Law
Section 201 and have Me right to eutMize"Written MMe remains of Me assumed. MylOur relationship to the deG1Md Is m
follwa.
Anna Grubs
OOS18W(Rw O&15) Page 1 of 3
Authoraatlon for Cremation and Disposition
lime ragaavnvl
�g IMb understate Net time remains are nor aaimed enter 120 Pays Mverydral
Pneu creamery
may tliepweatme rcmeNSN
an lveNevege manner, Mute as by uodvNg. wmacavrri
CREMATION CONIAMERAIRN
(indabONENme Mloxr'ngl
An un to the u%E ash ccnMiner brthe Analysed remeINIW Merl discovered from
are in Mounted as fdlksays
Wh understand that if Me on is Lo SMWI to hook!the Nine derreW rememe, an WMitlCnal Mgid container may W usM for disiaes,
*;1--An um is not red WrWsa1 INJe understand that Rno on is purchased or otHxAae proaded
Fine Ouw Cremmory
will 081 Me onemated arguing in
rwimacmmn)
a Mgitl IBmWrvy con1Mw for ds'ease
This Authorization Form and provided Patricia Miller
In was zaamnde M
Brewer Funeral Houle, Inc. � �
24 CNurM St, Lake Weerne, NY 12M eavvoma i
ate is Mail by Me Nneml reveal ae wMeu b by eaeWtgn.
gave have metered a completed ropy of die Aumorieetion Form.
The Pennants)ltlmtifiad Mlox made No,person(s) in cei of dlspmltlon,who My NBnireal this Autlwnvtian Farm, eaxtfs)
NO 1M accuracy and cam plNene9e 0 Ind i Minimal caMelned In thN AUNwianean Form and mutual the foregoing
spree Mle3 day ar June . 3021J .
Deborah Beyer o u As
318 Mein St., Coen, NY tall
aPeP
Awhe
Yar
Pal M lflAlll�salsW
PMritle Miller
r12465
Anna Grubs
i Beef(Reu. OL151 Page 3 of 3
Authorization for Cremation and Disposition
pored hMn the her bawl
Number: 9 BeawWen close friend
f. Apemn dowgraded in wrfin9 punmd be Public di lmer Simon Again 0);
2. The wrvrvin0 member
U. The washing demand parmr.
2. My schemes child egMeen years of age or elder:
0. AsmvMng panne
e A surmeg siding wisdom years of age or Oltler',
S. A kwNlly apMirded guardian,
T. My perwnp)Immune years of age or down mMlei to share in the eabro and wholshare dosest in reshuffled to Me Mas¢N:
0. A duly intended fiduciary of me estate
9. Acloses fraud or relative wont has affected aver an statement puresad N Public based Law Section 4201f]f',
10. AMiN fiscal ommrof a county or a public administrator apppnted punwnt to the SunOgele'a Claim PrCCMure Ac :
10s. My Men pawn who is wrong On career ofthe borrowed and are was ezeart a women Nafemed assumed W Public Heehh
Law Seddon 4201(1),
(or ALL IHREEIX the Mowieal)
IAW hereby a I min me b]y ofthe dereadid dab¢not inseam a battery, IMNery pack, power All Punched nodded
or Promtlrve aevlce and mad any s ihumorous were remover prior 10 the Wxuden d this Accumulation Form. Failure W Manua
mama theta MorWemnaYonmaymukinharmtotl cnmmoryandcrema" penomel.
kPursue MIAtt nQ�Inw amm cam maintains have been giwenW
regarding The removal many paManal proem or Omer mdrg dealer wndch am Person string f aow or any family member dfda
Pee New Cmredcry
dedwsee vista$to panel
m iww
is rem nwomime forme removed of personal items ban the consumer whom the dermas name demander. PamnalimmaW mein
uammeronwm me hardware will bedamoyal "a commerce potassium and moral bit model amrnmmadon.
iL O� pp Pore New Chemistry
�[]_IfNa hereby aumodx
W crowded me remain$ Of me deCe ,
FOUL DISPOSITION
The drawn informed to reduce ,command romdm name Answered!ham has coemeWrr not
Brewer Funeral Name, Inc.
Nam
24 Chu"or Wu -cmrw W 12645 510 W2]M
PLdress: Plme'.
TM aemadetl manal 0 derromed was be compound of as hNkwm:
burial in Holy Infancy Cemetery
If for any reason the Person named awes name not was premium of fide arranged roradm,
Pine Mew Chancery Isamhmked W ant possession m
ftaw
the remains t0 answer Front Hone, Ines s b/M9wms
a permco Mregimerea rtal' m� Anna Grubs
m..wnwwe
OOSl0 f(Raw. 00115) Ppe2af3