Thomas, Charlene Pine View Cemetery g Crematorium
Quaker Road
Quee nsbury, NY 12804
(51 a) 745-4477 Or (518) 745-4476
FUNERAL HOME: - .
---.-- RETURN TIME
DATE B TIME REMAINS ARRIVED AT CgEMATORY, (r4'
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS-
NAME-
TYPE OF CONTAINER: 1� II I1L �-CASEp
PLACE OF OFgTN:
--- -- __ESTIMATED WEIGHT OF REMAINS 8 CONTAINER
PLACED IN MOLD:
PLACED IN REFRIGERATION: ___ - --
DATE OF CREMATION:
TIME STARTED: -_ )412!
_._._TIME COMPLETED: YyGAN_
x)
PLACED IN RETORT; —M -);I)(
_-�—.__moveo: .-y-mAn
RETORT pIN WHICH REMAINS WERE CREMATED:
f '
a ?a-_F%tNfK_— Ij0q
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME Or ACCEPTED DELIVERY:
NOTE: THE CREMATION -L04 SHALL BE gFTgIxEU IN THE PERMANENT ERE OF THE CREMATORY,
///------iii New Ymk Sale
SEI Dii' Division of OMSKKIOFCEMETERIFS
STATE°F reColiCEMET CEMETERIES
°PPO0.11XIW Cemeteries °th A"°
FinalN "°
Y 12230031
e.(SIN Gel
wirewdocall
Authorization for Cremation and Disposition
Thus AUMorizad" Form mile[the coreplebd and signed poor to bad Ivory of remains for cmnal on.
Date:M/2020 Number: 103
crematory Name. Pine View Crematory
oueman Raw ,OueenaWry. W 1280a s14T4SMn
Addmsa: Pnme:
CREMATION IS AN IRREVERSIBLE AND FINAL PROCEn.
Cremation is Formed our by pleang Me remains M Me decreased and Me mMainer holding Me remains into a cremation chamber m
Meyare sAWed to inbnw heal and fl me. The Medan flame wNl incinerate and carsumaeprything exwpt Wm and mN .
which are all Malwlll he left altar cremation.
FdIMmN comment the crematory will been r ea onabk efforts to rermve all of the remains and other material"in the cremation
Member, bill some minimal dust and residue call likely Na led b ind The crematory all aeandelnudeme and f0 ign=tonal farm
tM remains and the inddeMl and foreign maleralwill be dispossel ae Feeuired by law. The vcnaled remains will be mechenlmlry
pulvenzed into small Preces and gemd 'nto a designated central urn. Csm WOremainsgenamllyaspulvsdz ur ino
staple fngmeMM recognlvde as Sk iBpua.
DPEN NG OFTHE CONTAINER
The uemNwy mainly open the aniNnIN holding Me unicellular! human remains In limited Mrumslanwa,SUM as to wnfmm day
idendly of them sed or to ensure that no mrmal is encbwd which might Injure employees or damage the vemmdy prapMy. 11
human remairs an delivered In a container which is net suitable for cmmdan such as ceremonial or rental casket,Me
Mabry will require Mat Me smaim be moved into a suitable container More Declare Me remains. The opening of a
COMammor the tan"of remains M remainawill be conducted Were a witness and all be done in away.wM Damly and ree .
IDENTIFICATION OF DECEASED
Charlene Thomas Married
Name W Deceaeed Marital SbWr
59 North Dr., Lake Wzerne, NY 12045
Limit Knorr Address
residence
Placr of Death
]5
sex: OM Ill Age: DOB. B/1n956 Data of Death:fi2/2020 Esbmared weight:_
Dereoptirn aceakeVvwlr9im!M wNM min ns Will he dMWY ,
Wood Bottom Crematlon Container, Matthews Casket Co.
MeNvl CONTROLOF°SPOSIIION
in canted or accuser Nin , w ONEWfhe hewMpl
1 anJWe are the demgnb agent M Me deWWed designated in a yet or women instrument exemed pmeuanl to Pudic
Haab Laws ion uoi.
q-�OR�-�
^b �ay� WJe have no knmadedge this Me deuaae executed a womenlnstmment purnent to Public Health Law Sedmn 4201 Ora
all wed ning direcdom for the dspmmen of his or her remains and WR are Me mraon(s) hating Prior"under Pudb Heath Law
Sedlon420laMheve Me Wg loaWM&emmation MMeremmnsW" deceaeed. WMurmlaeonlhiptplMde disn
Milwn: Chanene Thounas
DOS1806f(Rams M S) Page s of 3
i0thorizadon for Cremation and Disposition
brand the mvawwa)
� -%�move Montrea cinch wine random are na caimaa when 120 do"WManner.
vkv,Creedal
F as days Massiveof me romalna'm
evi
ervii
an melrlevanle manner, such as 4 Almrg.
CREMATION CONTANERNflN
bnddr ONE of M1e Yemeni nn
An um W use used as a consumer or Me normal remna d has been profea C]T or form Uyi 121/F�rQ' rraaklL
and is deecnbad as Mlwrs.
VJJe undenbnd dal nme an is use small to hold wn Some ensnared remain$.an additional dad onndoner mar be ralM dehVy.
OR-
An um Is nor yal Wrdased IMb understand that it no um is puMased or converted prcvitled
P'ma form Q ndMyry
do pi de command remains in
w..ao..vrr
a deal temporary,mnlmner W 4Awry.
Patricia Miller
Try AuMonms Farm was persevere by "a ereaRed at
Brewer Funeral Home, Inc. ra«.rnmx�
26 Church St, I-am Luzeme, NY 12M
and is firm d by Me funeral direarms as wilnm$to id esecNion��®r
INJe have reversed a tempi 4yy of Mis AuMarn Farm.
The Sunni 1dmlMed below Ware Me persomi In control of dispoe2m,vTo by signing Mis AUMoriaab'oa Farm,atlesV,st
to Neareurery and complNemec M NaiMomailon consul In MIS Authorization Ford and 2u onzNet Na fora6oll
sianea MIS 3 der of June m 20
Monty Thomas �� lL��,P
59 NOM Dr., Iake Wzeme, NY 12M
Sri
Al
save
WITNESS: sv
PNus Miller `I�1rTeu L�]4rYIW
omrnmmvmw
r 124435
Charlene Thomas
005-1596gNev. M15) Page JaJ
Authorization for Cremation and Disposition
ffmwffiwn Hre uanerow)
NunL' 2 Cerval husband
1. Amnon generated in Writing Pursuant to Pudk HeaXn Law Samon@o1(3);
2. The surviving mares,
as. The wrvWing domestic paMen
8. My surviving mild assumed years of age an glow.
A Asurvmng all
8. A wrvMy doling egnnen yeah of age Or oMw;
S. Alarva Yapgairnled guardian
]. Any perks )modern years W how or glow entitled t0 snare in the estate and who mare dcaeal in minima ip b the dev W:
8. A duyappoinled fidudary of Me eatalel
B. AWse earned or relative Who has execured a wagen 9aement pursuant to Public Heal law Sudden 0301(h
10. A Cngt fiscal officer Of aunty Of 9 W dic ornamental appointed WrauaM to Me Sugggele'a Chun Prm3dUn Act;
Ma. Any Otherµuagn lung leading on behalf the member and who has executed a wrillen&alement Wmmnt b Public H9aM
Law ma lM 4201(h
yr fortis ALL MREE of Hre/Mbwiyl
S
" ' — Age nereEy affirm vim fine body of the removed Mae not andiin a batlerY, b9rywy WrA, powder all. ndioafive imall
amdpeCti"tla and NManysudm91enalewe mmWWpnorbthee MionofthisAurncripOMFarm. I'mivabmmove
tlwae Items prior b cremation may mutt In Man No the Camabry and mamabry Porsorrnef.
I attlrmthW ins0dnmhaWbmngivenb Fell MiNw
assuming the removal of any Permnal pmpery or Omer Ming of value whlcn any person signing bNw'or any many member a the
Plan Yew Camalwy
deaaeed Waned to preserve.
vie via Raponvae rorme remoWl of Perspnal itemahom the OMtairrer or M1dn ilz rem&na orMe aeaeEM. Perswul IYma M m Yoe
mMelne.or W1M Me mnaln.win ba eawred M Ma mmson pr:e.a arse g.nnot w ao-iwsd.mr gr9nrauon.
Pine Yew Comalay
hereby wool
ic.+rrn.�N
b crytal Me mmains of Me demanded.
ElosPosmoN
The Pmhn summand to secure Me aemabd amain al d oW awn My vprnalpy an
Brener Funeml Hone, Inc.
Name.
Address 36 Chu" Sl., Lake Wraro, NY 12M 51e8gaPN
'. ppje;
The overall what atlxxmM WlI be demand a as falwra:
return to husband
If bt any moon the pwwn named above does na takep mum a Me aemled himaim.
Piravy"Cnmalwy
is aulhaiaed W give pose not
Me immune t0 Brewer Formed Home, ran n+.vmewxw by dellWry
in anon Or by rpiMrtG mail
Charlene Thomas
D08-18l Now, 08115) mr.n�m Paget of