Elms, Deborah A. Pine View Cemetery 8 Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME:
DATE 8 TIME pEMAI
NS ARRIVED RETURN TIME:AT CREMATORY- C RA��AFr...RIII NAME OF FUNERAL DIRECTOR ORREGRISTEREO RESIDENT DELIVERING(REMAINS:
(�°''� ❑ L _.__
TYPE OF CONTgINEft - -CASE A
✓ o -
In9FFwF- (on. r
PLACE OF DEATH! ZD -
"oPP_.Si__._._��('_11L1y_of
ESTIMATED WEIGHT OF REMAINS -
8 CONTAINER_
PLACED IN XOIO: _ __
_ 2_,,_m
PLACID IN REFRIGERATION; In
DATE OF CREMATION; ---'�----
TIME STARTED: yy --'
--71-Aft--TIME COMPLETED:
RETORT9 y{1QI�
PLACED IN gETORT:
— �._ 94 _MOVED:
% IN WHICH y REMAINS WERE CREMATED!
DETAILED REASON FOR DELAY 1F
REMAINS WERE CREMATED MORE THAN AS HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE pEMATION LOG SHALL DE RETAINED N THE PE Mn GRENT FILE OF THE CAHKATGKY
{ �I gRa New York
NIIIIEWYORK Division of OmsloxoscEMETeRIas
rzoF wecnnmeR ..w,^0
.
Cemeteries mcoany NYPoswr
eep Ae, Ael W6a3M
Authoriution for Cremation and Disposition
The Auer " ten Form most Ea empM and Old And Poor to delivery AN remains wr cdmim.
Dole 05/1 Numh .. Lag
cmmatm Nmw:pim Yaw Crematorium
Addase 51 Quaker Road. Oueensbury, NY 12804 France: (518) 745-0477
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
CRmaton Is Wmad Out by pladn8 the remains at be dxensM and Me mrMiner trading the Tmains Into a wmsOm tl mC rwlbre
May are Attractd to intense heat and nanne The hag and name evil mansraband consume svembltq ec<Kl Darya awl NO 1.
which am all that will be IM s rcmma .
Follwnngcremation, the IXemalory we Yb Rgonable effort to rampC all d Ma remains and Men mg al Nam to oematter
chamber, but some minimal dust and resitlue will likely be Of EehiM. TM crematory will separele lMaterNl and Mapn mgMel from
tw remain and themumnal and krei8n material Aral be disposed coss required M'Inw. The Cmmatadremaimmil CerMCllanlwlly
pulvenze Imp small pieces and plawdinto a designated wM iwr an um. Crx^ ransoms generally am puNer unfit no
dinem fragment W coonWMs Me skslsm l us.
OPEN NO OF THE CONrigi
The creno mry may any open her container holding the unlcremated human remains In IAnted tiumganwa,soot we to wrMrm MC
country dMe dismasetl onto ensure Me no m mmal Is enclosed shot might inure employees Of damage the xMMM progM- n
human ameba sadeliwrMIn acormerwhkh lanMSUNblemremn onsuchw MrM isiornnYloskMNa
mmgo will "Nine mattes remains be moved lead a suNabb container bgan Na¢spM1 Me r a ins. The claming of
container orthe"Aster or removal Mramgna will We anduMd beho'a a waa ce awl MII the done in givary.wiM dgniryand America
IDENTIFICATION OF DECEABEO
Name a Geaeaed. Deborah A. Elms Manor slams. Diwrced
Lag crown Pedrms:20 Raymond Street Corinth NY 12822
posse a Nat r 20 Raymond Street Corner. NY 128M
see OM 12F Ape: 63 DOB: OV0111957 Dole Of NAM. OB123/2020 EMMNtedwe 9h )
DsxN d wakethentamer in whiN rem ' ill bs deliveM I�
(Y�foaky s Cat �S�ho
PERSON IN CONTROL OF DISPOBRION
(Wrxn(s)in cancer!daspadhmn, we"ONE Of re kohn )
I arMYe m the designated Oil 0Me daessed manpower in a MII or Warren IreWment eaeculed pursusMm Public
HwM low S chon 4201.
OR-
IM1Ve Area no knowledge M ®a a Me deised eseWtea a wresen instrument pursuant to Public Neanh Law set 4201 Ora
nh nine teachers for Me diopo nion ahls An her amams and IM are NO portable)having fronds under Public Ibnh Law
seOwn 4201 and have the rgM m Mai common a to remains of the dewawd. O Or raletlanshlp to Ms dawseN Nil
mI w
DeboreM1 A. Elms
Plead
LbS18984(Rev. Mi Page 1 M 3
Authorization for Cremation and Disposition
lean hwn the lid MWw)
Number 3 pesvndorn Son
1. Aown "signaWdinwritirg Wrauentb Pudic NeaM Se 4MI(3).
2. Tie surverysmme
Se. The surviWng domestic Winner;
3. Airy surviving child eighteen years M age or deer;
A AmrvNing parent
0. A surviving sibling eighteen years of age or older',
S. A IeMully, appointed numyn:
L Any propnn)eighteen yens of age or older donned to sham In Me eadde aid who soon closest In bilateral to ter demdW:
B. A duty dpminted fiduoary N Me ester',
S. Acomae Mend or rel lve wM has eAwted a whenlowered wanted to Public Health Law Sworn@01(n.
10. A chief fiwl offiwr of a munry or a public economical appointed resonant to the Sumgatil Coal froyaressal Ad,
10a. Any other reel who is noting on brand of Me,ee0.Vsed eke whin mas mwutel a winner symement purchases b PWIC N M
Law green 4201(]).
amend ALL THREE N Me kYdWrlg)
Irwin hereby deal Met the body of the diamond does net wonder,a haderm merry paµ,power call,race burden Implant.
aM'iWdivedavkzand Meta"suchmatenalswemmmo peorm MeexmutionefthmAUMwma nForm. Failum Wm ove
Mesa Wee order W crematlon rosy Me In MM W Ma mnmetwy and crullers Memel.
AT
? Me 6Mlm that humorously Nam Nam owed to We tly M. Bulich
�I oree.r�.r
regarding Me need of any prwnN property or draw Wrq W wake whits any peen doing blow or any fame m Wr of tte
eemasee wahe r W meta . Pine Yew Crematorium
is nN msponsiele mrlM removelMpMonab llemB hem MB wnulMr�lne Rmems oftn eecaeue. ParemraflMsbft MIM
conhlw.o.xiM Me ramsles wall be Gaented by per rnmanon procwd end cannot be narrowed aXnndmatlen.
li release aNhmnae Pine View Crematorium
rvw adoemaw has re in Ncond 2W.
IMeI OPTIONAL)
May Mr y audience the named Nnewt director W provide der detHery W and cnmstlon by an amMas
commands,IF dx mcnsary In Me opinion of Me lumnl destroy,and to amend this form to provide the wnec[name and
adds OF such aMmew borrowers.
FINAL Ot3POSRION
TM palm endorsed to rar eMe cremated remains dots demeMrrnn the uerwtay Is:
Nana;Regan Denny Staford Funeral Home
Amend 53 Quaker Road, Dueensbury, NV 12804 Phmm: (518) M2-1114
TM essential reamym nicknamed!wall be dbymw des fdloxe
M
Irfor mrymmnM Mmsn- conedall.w of tlM OBIMWrIrlWnl.
Pine View CrematMWm a audedwd W grew wsmw*n W
the remains W Regan Denny Stafford Funeral Home by dmmeree
in person or b/reywred des, n..wmrww Deborah A. Elms
WS-184611Rrv. 04ore) nsme Pegs 2 W 3
Authorization for Cremation and Disposition
(lore awualyd
�y.{G pWa uMnN W Ind ntlq mains are M started MNN IM daysNaemgtian.
Pine View Crematorium may diapase mud nmelram
an inMmvapb sudden Whe as by swtlMng. were, d
�A�ON GI)INTAINIEFLARRIN
((R_al CNEo1rM1e/dbuing)
M as to Ce here as a consider for Me answered aware has Mn purMemd M1cm
end Is tlesmEeE as(ol loxs'.
Mile understand Met it the an is roo until m hda tie wAre wmatM remains an addlpaul rigid consumer string by uM lor dmarerr
-0R
—yy Mumbndy2lpuMlae NyarvAnaWk NMdmumispuMasedorrtMuls pronded
V Plne Yew Crematorium all place the cremated remalmih
m..wow.wd
a raid temporary container for dmiary.
TNe Au aaan Form wy pmNdsd by WBMV M. aNiCM1 who executed at
Regan Denny StaRON Funeral 14 me
53 quaker Road Duearrsbury, NV 123UA
and Is algmd by he fimael tinder she eidem b Its execution
IWe have heaven a centuries!sharp,Ones Authorization Fom.
has person(s) IdemMsd below Were 1M pacnal In wMol 0d4pdsNon,who by signing this Aunodaadon Farm, adeatlai
to the accuracy and chdngM nNa WInd IOwmanen caftinetl F tM1b AUMMiaWn Fmm and auMwlagsi din bmgding.
oyr n.,edthis 23N mya May
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Acres
WnNEK:
Welly M. BulicM1
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10961 1
Debomh A. Elms
tw�w�a
13 S.t ege.gMev. arzoi Pope 3d3