Reynolds, John Gordon Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME:
..__._ RETURN TIME: _
DATE 8 TIME REMAINS ARRIVED AT GENERATOR-T _
NAME OF FUNERAL DIRECTOR OR REGRISTEREO RESIDENT DELIVERING 2 �
_ REMAINS:
NAME: -- ---- Q1/)IJ r _
..
----_..
TYPE OF CONTAINER mh � ._CASE H _ �'-
tlRllnw3 . _
PLACE OF DEATH:
ESTIMATED WEIGHT OF REMAINS & CONTAINER I1L�. / V IIII
PLACED IN HOLD:
PLACED IN REFRIGERATION;
DATE OF CREMATION:TIME STARTED:
�7 'Y ft_.__._TIME COMPLETED: _ 1:
BpMn
Lvl. . -eJ
PLACED IN RETORT: _ _
._—movlo:
RETORT pIN WHIC .._ P:n . Bm An q 6
X REMAINS WERE CREMATED: "'1 1
DETAILED REASON FOR DELAY IF REMAINS WERE ACCEPTED DELIVERY: CREMATED �P -.� t-
FROM TIME OF MORE THAN 48 HOURS
NOTE: THE CREMATION LOG SHALL BE RETAINED IN THE PERMANENT FILE OF THE CgprygTOgY
York State
Mandy mein of State
NEWYORK Division of GIVISIONOFCEMETER1ES
aTAkp one Gemmem nus
OPPer Man . WWuklrgmnnrenue
Cemeteries Yrlvawml
oabli6
Rrami",am
Authorization for Cremation and Disposition
This AuMorlaea�o"n Form must be cWnphatee ana sign" pH«to axwry of M Slns for Cr afl8n.
Dale'. y 12I ZG Number. G 1ol1
Cre "Nome'. PIIre Vim Cremetanum
Address'. Quaker Roatl Oueensoury NY 12800 Phone'. (510)74Sd6]1
CREMATION IS AN IRREVERSIBLE AND FINAL,PRMM.
Cremation is turner oN by placing the real of Me decwaeE and Me container holding Me remains Into a mmaon chamber where
May are sublecl"W Intense neat and Ad".The Mat and Rome will lndnenb and consume everything eaGapl bone and me 1,
which are all Nat will be IBx aMr oramaxan.
Following cromati the Pemsldy will lake reaesaaNe eRMs to remoae all of the remains and other matadal from the aemegon
clamber, but some minimal dust and residue will libly be tell bRl The aemelary will sepamle in demel and bough material from
the remains and are incidanul and M ien mmmial will be disposed 0 as Muem repul!edbylaw.Tagd remains all be merborri Illy
prominent Into small places and pled Into a d"ag led COMainarwun CmaWd remains ganenlly am pul"dz" wall no
single figment is rasoMM le as skalawI boos.
OPENING OF THE CONTAINER
Ti matorymayonly cyan the wnlamer holding the munemaW human n®rma In Ilmil" uwmannras,such as W wnhrm the
Id tky of the dewmw1 an or ensure that no material is enclosed which might Injure employees or damage the crematory PMPeM'If
human remalns an dellwmd In a conlalnor winch Is not sulbble Her cremation such as ceremonial me re all caske4 Me
mselory M11 require MM Me nmalm ba moved Imo a so Stable cmbalnor bsfan xaempb bra remains.Try opening of a
wntelner or the Innahr or smooth of remains will be conducted before a witness and US be cons in prlval with dignM and reaped.
IDENTIFICATION OF DECEASED
NameNDemae": JohnGaudonliberyinsirds Martel Status: Widowed
LWKm Mdreu: 5 Elk R M Q b NY 1280A
PlamMDeMh: 63 Heart Drive 83 Helen Drive QumnsYwry W All
Sex El MQF Age: 79 DOB'. 08H6I19M Mai Eellmat"Weight. 20011
Crucial ofw.kaVwMemer in which remalns will be dolivered.
Agg(S ftrd !g"T(1'Sa'EL
PERSONDISPOSITION
IN CONTROL of DlsPw
(Penonlal W o*+fral of MmaaO'a^,=el ONE of me Wwavey
an eare the deslgnm"agent a the damn"derignaled in a mall or woman Matnmem emmul pursuant W Public
Health L,aw Sefton 4201.
Rpm
P Q INJa haw no kn wl aed8e that the deco Wexecuted a woman )ns"frounr pursuant to Public Heats taw Sedan Qbl or
II mnteiningdir ons Who dopssrum of his"nor remains and IAw are the Smal s) having pdorier under Public HeeM Lew
Season 0201 and hew the i to euMalw sremehan of Me remains of the dewesed.MuQur mlabomhlpbe Me deans" Is"
!allows'.
Jahn Condon Reynolds
INn+vnavmL
WS-1896f(Rev. o0115) Pagel of
Authorization for Cremation and Disposition
tinsel from d the cat ItiHai p
Number:1 D¢scdpllom 5On.
1. A Person deaRnated in wnbrg wrauent to PUNK Neagh Law Sed'm 401131;
g. The summing spousal
ga. Thor wrviving domestic PaMer;
3. Any wnlvinB Mild eignleen years W age or clear,
0. A wrvlving parent',
3. A sundvng sibling eighteen years of she or Older'.
G. A leufidly eppanled powder
T. Any person(s)eighteen years of age or ltler entitled W share in the estate and"aroom closest in readonMlp to the demased.
e. Ahaly aprointed fiduciary,of the estate;
9. A does friend or relative who has aremlM a matenstatement pumuaht W Public Health taw Setllm 4201t711
10. AMlef fiaml officer of a county or a public administrator appointed pursuant to Ub Sumegete'a Cool Protestant AM
10 Any other Porson vitro is aping on behalf M the damYed and of has executed awdNen statement pursuant 10 Public maIM
taw Sweden 4201M
^(Irai ALL THREE of Me fdbxin
1V gl
/ dlA INJa hereby worm Can the badyoltnr de¢aaM does not Contain a battery, battery peck, pmmercell redsmadve implant.
Carmicael"tlmice and thdarry,fuM materials areas Rmoved priorW the axeoNion of NMAUMOHMN Farm. Fallue W MMO
Mesa Items Oar to emm"on may result In harm to 1M cnmabry and Newport
� KLR IAm eMnr Metlmovgbre have been given W Mark K. Parish
regarding the removal W any perwnel propeM or other thing dvalm wbiM any pamon signing below or any hmlly member of the
decesaetl MCM1ealppreaerre. Pine Victor nrema um
is not reryvnaiWe far Me removal of perwnel items tram the confiner on from the remains of the de sed. Penmal Wma IaN In Me
container or wage the remMro all 11 ba MVayad by the rnmatlon p as and dntrot ba nuclear after CMMSUon.
111
IIWe barely authornts Pine Viers,Crematorium
WCr 2W Me remains of Me demased. sate
FINAL MSP ITION
el�pemn�leul om W RWWBMe mmatM remains of the depi from Me cremalery an
Name: ysi - l rvw.^-1 bi^ T"
Andress: /A Vital, Ca Kvabii 1 aY 193 q Phone: s/e 2W-rr �
TM tl&MNd lamelnt Nd ors Wil bedropmed Am mwaae:
If No any ration Ms person named eWme does not Wks pm6 On of for cnmaled remama,
Pine VI"
crematorium iswhod Wglvepoaemsionof
tMre aimw c dydeliMy
in person or by registered mail, nW.+oro-+w.vl
John (i m Reynolds
DO!ii f(Rev. got5) �wowrw Page 2 of
Authorization for Cremation and Disposition
Annual Was Wasearg)
EQ IrNe urdenrnN Met a the remains are nW claimed wilnm 120 days or vemetial.
Pina ViewcremModum mrytlbpmeathersommin
an undrinkable manner, such as WaGHMing.
CREYATON CONTAMEMRN
7WP is oom�
An um to be uwE as a¢nteiror br Me uemele0 remans Ma teen purchase]hwn
and is EeacnbMublMxn:
INJe understand than d the um is MO smell to hold the entire cemabE remains,an additional rigs tonsillar may M used for Celleery.
-0R-
A f!Z An um W not yet purNessid, IMe understand than s no um is Wrclueew or otMraue prmided(` Pine Ylew Crematorium a will plate the committed re rm na in
e NW tempoary container for Gelhrery.
This Assassination Form was pmvitlM by Mark K. Parish was aeatatl at
are
Carleton Funeral Home, Inc.
BB Main St P. O. Box Bi HUEeon Fella W12839
_kJarreentar
India signed by Me Annual dredor as wltneek bib execution.
IAwe may received a complains ropy of the AuftHm on Form.
T»penantsi MargMtl Mow Islam Me parents)In Moldy oA disposition,"a by signing MIs Augarhation Form, real
b the accuracy and canpaarrsss of Me Information contains al In Mh Australasian Form and euMadaatq Me bmgoas.
$land Mls 01 tlayof June X2200 /. n
Richard Reynokm
83 Helen Dirres Queensburri, NV 12800
rwnaw.rmA
MNESS:
Mark K. Fanah
z
Ja rn OsMon ReynoIds
OOS 18"4(Rev.0M15) Pass 3 of