Floutin, Christopher D. Pine View Cemetery 8 Crematorium
Quaker ROad
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME:
—
_--_._.._. _. ... RETURN TIME: _DATE 8 TIME REMAINS ARRIVED AT cgFMATORv: - --
NAME OF FUNERAL DIRECTOR OR mmRISTER
ED RESIDENT GE
DELI VeRINO REMAINS:
TYPE OF CONTAINER: __-_- m CASE p
*`_ncllwRf �.
PLACE OF DEATH; _�bn.20I�_
��R F
ESTIMATED
WEIGHT OF REMAINS & CONTAINER- I1
PLACED IN HOLD:
PLACED IN REFRIGERATION; _ ---�
_-- -
DATE OF CREMATION: -.
TIME STARTED: _ p—q - -- —m-- --�
_TIME COMPLETED:
PLACED IN RETORT: p
_MOVED: _._ $_i {�1I NN
RETORT p IN WHICH REMAINS WERE CREMATED: - -Ile 36 'j,4M
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATEO MORE
THAN
A! HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SMALL BE 0Ei91HEO IN THE PERMANTNT FILE Or THE CN ME AT qp Y__
�Ment of sums,
EWYORK I Division of DIVISION OF,Open'..dIM
ome
DF era
^ Cemeteries w wa° fivai
:Ptoml
w"'.IbrRarvaxl6
Authorization for Cremation and Disposition
This AuM futron Form must be comPlebl and AMNd Prior W dellwry,of Mmi,,M eremMlon.
Gate Lugn Number: 101
Crematory Nyre:are Vtau CWmam m
Addmas:Quake,Rapid,Dumnmboty.My 128M Pmm SIb 7Mr-MYl
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation La carbM out by Placing the nmaim WMe decea6M end Me ogn0lrer MMInP Me maim,into a Cnewcon chamber wort
they are subbaed to Intense heal and flame. Th,wadmol flsma well Inch srW consume maMbtng nnpt Mna and mental,
which an as that will be Ind altar wamXlon.
Following aremml be crematory MII Mks teas oWe epoch for o all of Me w hi and other Malawi from Me Ombei
chamber, Out aims minimal d ual and residue wil likely De loll b rd. The cromeNry WII separate i nad ental and Owed n melema l from
the remains and IN Incidental and bnlgn mabnel wM ow day and of as requhen by law. The cremated remain,will be mechenMelty
puivertak Into wall pieces and Al into a detignered wnwner«Law. Cremated remalm genarilh an powerful will no
Write fragment Is recog n India a,MnIeW Name.
OPENING OF THE CONTA NER
no mine"may only open the Cenbiim nothing the uneranend human remains In timMd arwmganus,much as to confirm the
Went"the decti or to ensure mat on heard lm anaosed welch might mlure employee,or damage Me uematory property. If
human remains am dNlw,ed In,a crunwrivi is not nufti for cmma", much aaremonbl ornmal Merger Me
chremortory will"i Mauna remains be moved into a suitable Moral before It ccepts We remains. The opening of
container or Ma harder or removal of crowded will be canduch d before a wMess and win be done In piracy.Wii h d'pnily and ro p acL
DENPFMC ON OF DECEASED ,� �, ��a
Name Of Decreased t ased: 3 wee �n /DO MenAdSbllq: ftab" -
teat Known Addresup L (C 11 feet !
Pare of Death: ZOTi 15 T 4' IP T l Itgi
Sea ®M OF Age: 94 DOE: 512SI" DaWaOwM: 6 l 1 zO Eatllrlabd We htlX
oescnlAon of U,Mvmntalmr in wNch I mMn be dohnsho.
M + COLIbbod In l P 'I Iris,J k, ko te e
PERSION IN CONTROL OF DISPOSITION
fPoamRl in anchor of dorb rm. imaaf ONE of the Mbvtirgl
amNh are me designated agent of IN MdMwM containment In a Mu orwrawn instrument eaemed puratiant M Pubic
Human Law 9xrlon 4201.
-0N
-PIN,have no XnmNedge Pat the de¢aaed ux Wawntlm Instrument parent to Public III Law Sac again ore
cent containing dlreMonrtw Me di posihbn of has or her romaMs and IMg an Me paaon(sf Mnry moral under Pubic HwM Law
Section 4101 and have the OEM W au fence oamatien of Me remains M No doodased All MaOmhlp W have 400v In as
follows:
c1rivioppar .-din mm.,.dr—.....�
DOS18931(Rev.04110) Page 10S
Authorlutlon for Cremation and Disposition
flnwd)ram(he0d0ebw)
Number: y Deaaip4al:
1. A"men dedgnaedln wrong pulauanl b Home:Holed Lax Shaderl<201(31:
x TM carding apuue:
m. The surviving forward panned
3. Any surviving Old eighteen ran of ago m olden
A Amor it whantr
S. Asurowni sibling eighteen yard of age or older,
& A level appointed guardian)
T. Any(ara lsl eighteen yeah Of pe or older enlXbd b sham in the el and who aware dmtl in bolstered b MV LaauveE:
B. Aduly appointed reform of the mein
0. Adoes mend car intro has awcNN eenXen statement Permit b Pulls Health law Section 6201(7
10. Adeval fiawl oNcer of a cWnty IX a mudb administrator small Wmuanl b the Simgar'B Court Prccsdun ACC
tee. Any other Mercer Mob soling on teNll d Me Mamased and who has evaded a vol Statement feel b PI Heats
bw Secim 4201(t).
(neal 2-FEE ante bttowng)
E(�Jf—WJe homey affmthmMe Mary Of the deceased dome net mMana be" bell"Ar Power daval bad\ 'M"M
ormdbadrve device and Me artysoon materials were removed Nor to the execution Of Mh AUMO On Form. Fellumbmmeaa
ew{v�e Items prior to cromall may result In ham to Me Memel and mroryno m " rmal.
4-f—Il again Mat ndrudgne have bean given to MCM1 M. Pansh
himm y the removal Of any personal prop"or oNn Mng of Made all any pBncn signal Ml Or my rMry member after
damaged wbhae b mramew, Pine view Cremabnum
from
m cal reapongide far Me removal of Wnonal terms Imm Me mother or hcm 1M remains of Me deTaM. Penonvl Xamv IaR In its
co{ntainer,or will the remains will M barayed by the amnalon process and canned Xs
achieved after emmaMon.
J/ f—Me Muter metal Pine View CremaoMm last
b emmvr the mm ns d the decaad.
Neither OPnorvay
p�LNv hereby memories the named Nam)Meadow Wprovide for dvlwery to and cnmNm 44 an eMmaa
Minnesota Rdwmatl n.me.sum In Me opinion of Nanl director. and b amens MIa firm le Provide the correct name and
address of flesh atemm Moral
FINAL DISPO Kell
Thepmon au ohmd b noneve Me Wnmiins of m0 loosed arm to nemabry Is:
Name:Carleton Faced Home, Inc.
Morass 68 Main St HWgan Falls, NY 1283E Phone: 518-0I74243
The Deviated roman.Of Mnwdwm MNapm•a made ldbn:
n rm.m maroon Ms Wnm nanwa.MM.ode.boarb.paagslm ante dremard nmane.
PIn Vm'cmmaMum a marmalW giveW muk M
Me romansb CMaon Funnel Home.). bydelamy
In Wrem or by"massive bell. mwmreyyp ClS�r L« Fler.dl., mn.xm�
oDS1898 f IRev.(i U� Peal 2aa
Authorization for Cremation and Disposition
A" Me understand that it"nmYm am mltlelmea wMln 120aeys mammon,
mtm Vkwcrwmm m
rvywtl may cmpMe of Me mmYns In
an XreMrvaew dinner such as by scattering
GBEM9m14 WNTANERNag
fladdaf OW oflhe diamond
M on to ere eve as a mMWmt be Me cematea mmYN IW town pumM1.W M1wn
and is amchON as Raises.
Me understand that it the am is too emee to Wit Me entm aemaba mmeym, an adaedW xgm¢Memel may In,need in,do...ry.
.ors.
llf
j M um b set W pACAssm. 100 maembna Net H no who purchased or MMtMm pmuMea
Pine Vlew GammMum We pace W 4wmtad renuFS In
yr.acwm
a Hgel tememary cnminer for dawry.
na Aullwtlmibn Fame wad provided by Mark K Paris wasemwW M
Cadebn Funeral Home, Inc a u.«tiw
iniwwnm
U8 Main St. XmanagersmanagersAway.M' 12009
and is Rained by Na fantasy ditMor ea witness to its BM=M, a
lMe have moneyed a amplsbd ropy M this Authorizatlpn Form.
The Monsanto) IdentlMa them beam the psrmenlel In central d aespoNOoq who by signing Nb AtMadvatln Fumy,whi
to the nsuracy and wmplemmss of the Information contained In Nis AuMMaetlon From and sNhor mis)Ns fonsgobq.
Menisci Zh does . Inns, ,20�_.
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