Ruark, Lois Marie Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 Or (518) 745-4476
FUNERAL HOME: _ E�,�
RETURN TIME: _ pof
DATE 8 TIME REMgINS ARRIVED AT CREMATORY
NAME OF FUNERAL DIRECTOR OR REGRI3TERED RESIDENT DELIVERING
REMAINS!
-------
NAME
TYPE OF CONTAINER .-CASE #
_ .. fpr:¢yl.l a2�lur®_ _.�t_._SkF (/ hRx38A�
PLACE OF OEgTN: �(
ESTIMATED WEIGHT OF REMAINS 6 CONTAINER_
PLACED IN HOLD: - -- --�S
PLACED IN REFRIGERATION: ____
DATE OF CREMATION: �----
TIME STARTED:
--
PLACED IN RETORT 7-LiLL
- Rio
__- L-MOVED: _.-_- S Y __I_. ••I q RETORT PIN WHICH REMAINS WERE CREMATED; , -_ �
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED E THAN 8 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION L Go SMALL BE RETAINEDIN THE PERMANENT FILE OF THE CR M¢ gioav
Authorization for Cremation and Disposition p..�mm.n<aNmisse,wwv,alcamnewµ.ne.o,
Aces,
aAI47thisa
cw„i
TbM AUModzagon Foam murlbe cpmp dsignWpd W WMryof remains forpramageR.
Date. C . Number.
Clemepry Nerve: J Frio View Crematory
Retirees: Quaker Road, Queensbury. New York 128N Phone'. 5181]45449]
CREMATION IS AN IRREVERSIBLE PNO FINAL P 100sig.
Cremation is carried out by placing the remains of the deceased and the container holding the remains Into a
cremation Chamber wherethey are subjected to intense Ireland flame.The heat and flame WR lminerett and consume
everyMing estate bone and meal,whlob are all that will be WE:after nervation.
F of lowi ng cre matio n, t he cre m ate ry wi ll rem reasons In le efforts to rem ove a n of M1e remains and tithe r mate nal fro m t he
cremation chamber, but some minimal dust and residue will likely be left behind The crematory will separate incidental and
foreign material from the remains and the Incidental and foreign material will be disposed of as required by law.The
mated remains win be mechanically pulverized into small pieces and placed into a designated container or um. trema[¢d
ages generally are pulverized wall no shade fragment h recognizable as skalds)true.
OPENING OF CONTAINER
The crematory may only open the container holding the un-cremated human remains in limited circumstances, such as to
confirm the Identity of the deceased or to ensure that no material is enclosed whim might injure employees or damage
crematory Property- N human remains are drib M a container which Is not suitable for cremation such as a ceremonial or
rental casket,the chemistry will bases that he remains be moved Into a suitable container before it accepts the remains. The
opeang of a coninar or the transfer or removal of remains vial I be con d her ed before a witness and wuI be done In privacy,
with dignity and respect.
IDENTIFICATION OF D 1E µ C'liASE`D I,
Name of Deceased: qI gs1lanp Lary. Marital Status: yiyHp Xh
Lae Knpmt aeareas: 191 I Ifpvm Q.( l�llee ant [ 1'(AtrL
Place of Death:-1-tit rt loill 1 aA1� 1'14
Sex. DM dF Age:-L DOB: 0S 1QP..l 11 Data of Death: Esiima[etl Weight: ZS
Description of casket/container in which remains�will be deli—veret
Corrugated CardboardBox wish Plywood 5 rk Mod Ig3880
PERSON IN CONTROL OF DISPOSITION
fersonts) in control of disposition, Initial ONE of the following)
I am/We are the&signaled agent of the deceased designated in a will or written instrument executed pursuant to Public
Health few isctlan 4201.
OR
/ 4 I/We have no knowledge that the deceased executed a written instrument punuant to Public Health Was section 4201 or
a well containing directions for the disposition of his or her remains and (Continued next page)
Ufl'Q oxu CIAO
oossesa-,Inn.ayso) xmrealvvxwvw rx.zws
' IaIII are the paraols) hvinng p^otM under Public Health bw Statical and have the right to authorize cremation
of remains of Me demands.My/Our relstlonsklvto tbedeceasW Is arfollows:
FlmMjrmm the list below)
NumbG_�L_Dwmmcbon'.
A person tlesgnared in writing Purse bPUNic Health tax ettilon 420113);
2. The surviving spouse:
U.The surviving domestic partner',
3. Any surviving child eighteen years of age or oldeq
a. ASurviving pages;
5. A surviving sibling eighteen years of age or older;
6. A IrNulty appointed guardian;
1. Any person(s) eighteen years of age of Older engaged W share in the estate and who lslare closest in
relationship to the deceased;
I. A duly appointed fiduciary of the estate:
9. A close friend or relative who has execttetl a witern statement pursuant M Public Health Lase§1201(]):
10. A chief fiscal orecer of a county or a public administrator appoinetl Wrede d to Me Sumagate's Court
Procedure Act;
figs.Any other person who is ischng on behalf of Me deceased and who has executed a woman statement pursuant
W Publac Health Lax§4201(7).
lmirialALLTwaffu/Mejofwvwpl
tN I/We hereby afflrmthat the body of the decreased does cast wntaina battery, battery pack, power cell, radioactive
Implant, or radioactive movies and that any such materials were removed prior to the execution of this Authorization Form.
Failure to remove these gems prior to according may reach N harm to Me commoner said minatory person ed.
rN I/We hereby aHum that Instructions have been given to pweNamv eml CassaPaNem#14W regarding the
removal of any personal property or other thing of value which any person signing below or any family member of the accessed
wines to preserve. m,,z".ml Pine View Crematory is net responsible for removal of personal
items from the container or from the remains of the deceased. Personal items left In the container or win the remains will be
destroyed br Me cremation pr ai and cannot be rexlevN after cremation.
rµ I/we hereby authorize suavrvaso Pine view Cremation, remrte Meremams of
the decreased.
FINAL DISPO51Tox
The person authorized M receive the chartered remains of Me decesesd from Me crematory Is:
Name. Baker Funaral Home Personnel
AELasn: 11 LiefirseltheSlagget, Quarrelsome Masir ydi; 128N Phone: (518 T61-9393
The cremated remains of deceased will be disposed of as Follows.
Realm to family to bo separated
If M any reason the person named above tloes not take possession of the cremated remains,
rcrwnowsy" i Pine View Counsel is auMonzed d give Possession of Me remand
WZNmmenuavi Baker Funeral Home by delivery In person or N registered mail.
talc y\Y �yuxII
msraxulnn.oLsol xanerpgaaN PNexMa
rr�irml deNnowmpl
Tµ Mae understand that if the remains aremttlaimed wynin 120 days ofco eYcn.
!xw^wwrs m l Pine V CremaNry may dish OMe remains in an inebievable mannw,
such as by wertha .
CREMATION CONTAINERNRN
(Ii ONEafthe MN wing)
An urn m [6 used a;a container for Na command remalM has bean purchased from Bake!
Funi Home and is described as losses
I(Ae understand that if the um is too small to lwld the entire cremated remains, an additional rgid container may be used
for delivery.
-OR-
11tM um has not yet been purchased. Ili undersand that R no um Is purchased or otherwise provided (w,, xy
e") Piney Crematory will place the cremated remains in a rigid temporary
container for delivery.
This Authorization Form was provided by uvwi Gssla PalferN#101W
was executed at dwrwnmremmJ Bakal FYnelal Home
(immOn revwa..I 11 Lafavath Street Oueensbury New York 128oa and is signed by the funeral director
as witness M its execution.
VYde have received a completed copy MMis Audwrizadon Form.
The hardships) identified belowis/are the penitents) in mnbd of dlsposhion, who by Writing this Authonzation
Foml, attest(a) to the accuracy and completeness of the in/wmatpn contained in this Authorization Form and
authonze(s) the headless.
slpred Mb played 20
opevivwri sM
a , MMUT
WITNESS:
w dw =1:2 h
Funeral Home Rea. #0113D
wmirvoew.v.me..
ln � hie Quark
Duce r Piece.OVIal a ...a✓a