Robillard, Barbara A. Pine View Cemetery 8 Crematorium
Quaker Road
Queensburyl NY 12804
(518) 745-4477 Or (518) 745-4476
FUNERAL HOME;
-_ rj__ [EnkfL -- -- RETURN TIME:DATE 8 TIME REMAINS ARRIVED AT CRFM I
gTORY: ll y/ .p.
NAME OF FUNERAL DIRECTOR OR p YE,
EGgi$}EKED RESIDENT DELIVERING
REMAINS:
NgME,
____._�nRggBP!_.BD�Fu9RD
TYPE OF CONTAINER . REMAINS-
CASE p yy�
PLACE OF DEATH:
T�la1 ....
ESTIMATED WEIGHT OF REMAINS 8 CONTAINER _
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION:
TIME STARTED: �—
JO p
{ .__.__TIME COMPLETE@ _ Ao a) pn PLACED IN RETORT: •Y-L
�.y(R . ._._MOVED: _
RETORT k IN WHICH REMAINS WERE E CREMATED: 7 .j
REMAINS _ 9.D 9
DETAILED REASON FOR DELAY IF �t -
9 WERE CREMATED MORE THAN 4B HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION L04 SHALL ME RETUNED IN THE PERMANENT FILE OF THE CREMATORY.
DepWme aaS w
NEW PORK Division of M MM OF CEMMMEE
STATE OF One Commerce Nina
RI UM Cemeteries npbn<vznue
L NY 12231,0001
Teleu e'.ISIe147i
wwwavenso,
Authorization for Cremation and Disposition
Thai AuMwlaerion Form must Ca compbbd aM signed prior to WNwry of remains per cremanen.
Dale:Jules 2020 NurMer. . , Do
Chamber Name: Fire craw Chancery
Address. 210wker Rwd Owuisdlry.Navy Yak 120N per: 518-74kj
CREMATION Ice WI IRRE RSIEILE AND FINAL PROCE8.4.
Cremation is limed out by placing the remains bathe deceased aM the container balding Me remains into a oemoon chamber where
they are subjected to intense have and flame. That beat and flame will lWN W And mnwe svmNhjlg neaps bone and maW
%much am all Mat will be left after rnmal
Following cremation the crematory will ake reasonable efforts to remeve all of remains and other mad ial NOT the aemccn
chamber, but some minimal dust and residue will likely be left behind. The thermal all rani inodemal and foreign material from
Ihi remains and
email pieces end Owerginto adea9atbalecostaned or ronu'remxbdmmal . 11ynamlwnve d tlirnnF&W
to Teri: or um genera pu
smgM fragment M mcognizable as skeletal Onus.
OPENING OF THE CONTAINER
The themeWl may only onen the container holding Me umaemaled human remans in limited circumstances, such as to fenfmm tle
identify of Me managed Or to ensure that no matemal is enclosed whirm might injure empbycea in damage the v malay pmr N
burns in remand;am MiiwrW In a conbiMr which Is not suitable for cmmatlM such as ceremonial or rental small the
moved
Wom
e remains.
il
containerr Me aansferwattmevel of remt Me remains ains will herconducted befonto a suitable re as writ rase and w`II be doe un steel with dignitynFnri respect
idin CATON OF OELEaSEO
Name he Decea W Bilateral RcbAIBN Menw Steals: Dhahmd
Lae Mom Address 2 ON West Rwtl Gm 000, Nes York 12831
Place of DekN: 2 DM Wnl Road cement have York 12831
Feb. 17M El Age.66 DOe' 11-27-1953 Dare m Cloth' 805-31-2020 EBBm WMM 150
Dexnpdon of cnkeumrdainer in which emains set be dNiverBE.
Florence Casket, plywood Corrugated cardboard container.
CONTROL OF MN
(Porsm(s) in OOMcN ordispo ,, M ;ONEn",'venerequ
I all an the designated agent of the dereasad designated in swill or small Imhhiment executed pursuant to Pubic
Heath law Saliba 4201.
-OR
lives have no knowledge that the decamped exealW a written Instalment Pursuant to Public Health law Section 4201 m a
containing Mregions for the asposNan Of his or her remecs and Ihre are the persw(9)having FmonW under Pudgc HnIM law
9eclwn 4201 and have the right to Amorize cremation of the remains of the deceased. MyrOur miadonemlp W Me deceased Is As
%lid n'.
Barbara A. Robillard
DOS 8i(Rev.0A201 Page 1 Of 3
Authorization for Cremation and Disposition
(1011' MebNowhg)
_IM R VWeu ffMnduardMemmamaarenWaaimedx in12otlaysuraemelbn
pm Yaw Clambers
my depend of MB Rmelne In
morp mry
an mmmuwvame manner. such an M scattering.
CREMATION CONTAINERNRN
(i aal O/INEdRa holbgf vnr
1111'l M um b Ce used an a commit fa the amended intense has nepunctuatederpunctuatedteam M. e. Klm Funrt m
er al Ha
and is Mainland as failures;:Gamemes Medal Green
Ii underslaM Met If Me um is Mo S"I to ME Me en ire ttemmed remains,an Mtlidianal ri0M acnlelrro'may to used V Salinas
OR-
-Mumismyepu"a 1. 1 uMer dmmffwumispulchawwctmmliseao,
Fine V'Nw Dormitory will pi the rearmed remains In
a mail demparary mrdalnerKK delivery mwamw
This AUMakatlon Form was anomi by Claim C.KomaV was execule0 at
m'�+savreom
M. 9. Kenn Funeral Home
s...unar.hei
136 Main M South GGlennFalls, Many o save 12803
and as Signed by He,NneM dirM«as vMMeeto as machine
head have rewired a completed copy of thin AUModaamn Form.
me permamle) i&ntmw below iwm th purbonls) in conliel M dlslocal cobs by signing MIS Statistical Form atlnngel
etheraccuracy and completeness of Me Inrormmdn contalmd In MIS AuMoriaa0'Wr Form and auM (s)Me/areg^ina.
Signed MIS 01 day M June .30 200 .
Megan tee Bawemo
121 FOn EMaN Road Fret Ed aN. Naw York DRM
names
WITNESS: , p
Claire C. "Siste r e 1
11832m vm.samw
R,rara
p Bekam A. RobyMNMeyr
mmremoe.b
DOS 18Wf(Rev. 04120) Fyp 3 W 3
Authorization for Cremation and Disposition
Onasrf Men the led Wow)
Number Determine, MY Wel Mild eighteen yeah of age or doer.
3. A lessommtleugnamem wrung puma",up Pudic Heats few Setl'rn A3(I1(3):
L Th. e surnivirg damnatic human
3. Any au red d Mho NgMeen years of age or older;
A A surviving "rem
l
5. Asho ing sibling englteen years a age or olMr',
6. Alawlully appointed against,
T. Any remand)eighteen yound of age or alder enNled to share in intestate and who iYare classes in relationship to llre disposed,
e. A duly appointed fiEYciary of Pe adds.
5. A dow Mend or relative wher has women a wilier segment pursuant to Fu all Heahl law Section 4201(171',
10. AMiN fiscal oMm of a county or a public admimsttatm appointed Wnwnt to the SwrtgMs's Court Proposal Ad:
10a, Any and parer who is adding;on hMelfofMe demanded and who has switched a written sowtarem pursuant to Public Health
LAIN border 4201(7)
Al Thl of fete Wowirgl
LA AM hereby affirm that Me body of Me deceased deals me crown a battery, Wftq pad, ewer reLL radmarive implant
Of redlcarlue del and that any Such maledals more removed poor to the ewea00n dome Matchmaker Farm Fallwatormave
d�xl s items
Pays to dmwMgWn may r uh In Ntm to day cnmamry and cmnemry p onmi.
1 r Il IM/e affirm that Inatnrbnz ham Won given m Claire C. KonopFa
l
regaM'W the removal of any personal pmpeM orother thing M value whodo show ry Rea agnirp below or any family member of May
deconi MMes to preserve. Piney Guarani
'a not respoMible dMe remMal of Perzmal ihemaM1dn lremMaial from the remains of the deeeased. Nmonallg Sla in me
CwwwwilM1 av remvins will be eevboyw ty tln cmmNlen Pmaass.rW wnnM be ntrleved aeercnmeuon.
08—lMw herby armorial Plan View Cremmary
e.w",n.w
w emmaw me mmain of Ma acne d.
ill OPTIONAL)
LW hmby wool Me named funeral dlrecmrto provide far delivery to and mmabon by an shipment
mmabry, if Ce m necessary In e opinion of Me funral director,and to amend this farm w Perform the counsel and
address of such alramm eram.mry.
FINAL DLSPasrt oN
The person ammulned to real the aemewd deal of are dereaaed from the aenage,is,
Name: M. B. Kilmer Funeral Home
Pull W3 Mat" bh. Seem Glem Falls, New York 13803 Pam. 518-74!id116
The channel remains M debased will nd disposed of an mope&'
Will Railroads Category
If fa any raasvt the persm named above does net owner Poazenlm ante damaged remains.
Pine Yew Cmmapny
reautnMzed to nor Poaaeaaion or
M ,remainro M. B. Kluwer Funeral Hen PVwr _ by dellvery
in person or bJ regielaW mal Pwbwa A Rebound
nv.+w�a
DOStsglrf(Rev. OZTM) Fel M3