Baker, Thomas C. Pine View Cemetery 8 Crematorium
Quaker ROatl
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME; _,- ..- pSNSME� -
___OATF B TIME RETURN TIME:
REMAINS ARRIVED AT CREMATORY: 1
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING'REMAINS.
NAME
TYPE OF CONTAINER: /��- -- �CASE p J 1� -
PLACE OF DEATH; � / ��-^�• -^
---- - ______ -�#- � nays
ESTIMATED WEIGHT OF REMAINS 8 CONTAINER_
PLACED IN HOLD: '_""--"-- -..._IsO
Lld-
._..-_..__
PLACID IN REFpIG-�ERATION:
DATE OF CREMATION:
TIME STARTED-
__ L.� gy1
-'-�-- -�R}__ TIME COMPLETED: _ ,')pP
PLACED IN RETORT: L)�I(O --SI-I
- - _MOVED:
RETORT p IN WHICH REMAINS WERE CREMATED; ,$ ftf
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED ♦
FROM TIME OF ACCEPTED DELIVERY: MORE THAN 48 HOURS
NOTE: THE CREMATION LOG SHA
LL OE RETAINED IN THE ppRMgxExi FILE OF THE CREMATORY.
NEWYORK Division of O1^81Oo°P x`"I^g STATEOf
OP1,0111Y Cemeteries IstrAlairproi ul+mv.tn'13>fwoor
iMeplima:15181g66II6
Authorization for Cremation and Disposition
This AWMiNon Fbml cowl 0¢conwM and Ngnsa prlar by E81"of mm ns for manau.
Dtla: =31QC3o Nww 41�
Cremawy Name. Pinevlear Crematorium
AdMredd. 210uaker Road, Ou OUq, NY tf&N Preprod lS)TV4Mll
CREMATION IS AN IRREVEniOe ANO FIML%10CE33.
Cr¢matlm is tamed out by Owing IM moments of tM araaai am They container Mldre me remains irllo a crem chamber wnNe
May are subjected to banned new and name. The INM and R will mnnxate and Immune reasonable smaller bons and delµ
which are all May are be NR enter neural
Fdbvnlp cremwbm,Me uemalory will take KeMned¢ellom to remove all crime remN ns and dM material from The uemadon
chamber, but epne minimd dust and raSdue will likely be tell behind TM cnmetory will pe�a�¢brtldeaal alq/meign meleritl M1gn
me remaim ana die'maaenral ana kregn matexel wiuceaiapased of as reaure]Iry law. The=ma mmamswilb xNn'I
borrowed Imo small paces and (ladedinto a amended container or um. Cm domains Shrimp am pulma ui as
single fmgmmtb Ncognlable as SMw lb us.
OPENING OF THE CONTAINER
The uemwory may only open the consumer holding the un-crenated human remains in llmihdtirclvnstarces, much as to confirm be
IaeaM of Me awarded or to mwre Met no maleral is mewed Which seem taut wholesale or damage tlw GeMe mpdop x
hum maim compares In acompares win t m Is not suXabL NmafI for C such u cremonlel or nM musical,almusical,Me
wnubry end all ultra Met Me remains be moved mill so lteble container Wm Aaccepb me torahs. The omrieng OF
rap or be detester or removal of remains Mn ce conducted theory a always am W11 be done in gbvMy, wM agnit M woman.
IDEm FICATION OF DECEASED
Name Ot Demesne: Thomas C. Samar mamiswu Maa
hall Known Awards: m Nammury Rmi, SImy,Chp NY IM70
Plard of Oa&n: BBHan4w9 RW. Story Creek,NY 12813
Sex: NM OF Age._ 72 OOB.. Wn6119a7 glee Ceeyi: O5300020 Eamded WegK
Desorption of emanational in wTkh ranins Mp h aNMPed.
typernatenalrmWeumanufacdrer) MwnKwa Aware wwa are car wcmma C iw
PFlN10i3IN CONTROL OF DISPOSfflM
fPa m(s)m ccnlydofdspovCn4 jp�gl oNEdMe Mlowmg)
laNweaetlwaatgnMedeaemameaereesMaesinm inawlaarwtdten InswmmtexeclanlNmaato Pubnn
Hall lax Sxam 4201.
OR--
✓¢ WJB hang no unrave e that Me disclosed executed a appear instrument commented Public Kup law Section 4201 or
Wflm meadows ficar M¢allocation of bps or hertemMm aid IMeare the "men($)hmMp Worry under Pull Hmlm Lew
sectim l2ot eta Nva MeryMmalnnon:e dremaGen of lna remmna atMaeceased. WMurmNdOm 1pmduaemasdisn
employee
Thomas C. Baker
ap
DOS-Iasi(RBs,wOS) Poge1 013
Authorization for Cremation and Dispoaitlon
(Inu tom the namasw)
Numwr 2 tomorrow 3wMry SPalse
1. APoracn dmigne In among WnwM M RNS Paul Lax SxEon 4ID1(3):
2 The suMaing spaces)
U. The wMNy Oomestic GMef,
a My eurrlving rnim eighteen airs of No vatler;
a AeorvlWng Parent
9. Asurvnmg eiouy ey"n years of age Or bigger
S. AIaMUlly apparel grant
). Any perm(Pgn years of age or pkM WMIBO as share in the estate ark Who moure stood In MWIWahlp bins GCGGO,
& A duty adverse fall of Me estate:
9. A dose hleM or kayaks who has executed a Wr aW OM pursuant to Public Heahh Law Will 4201(7);
10. A chief fieGl ptRGr M a¢ "wa sugar administrator epyinletl pursuant W to Sung 9Court PrM90ure AG
We. My other parson Mo is a4ng on der M Me Mceasd and and,has emuMd a%fddd statement puMe tk PUCK HB
LaxSMlm d]Ot(]l.
IAl hall a arm tat tb body at Me deroas al does rid Wnkin a datery, Worry pack. career GII, redlwNve ImpynL
M redlGNve de eck arm most any EUM mammas"to remM9d pithy the residual of Mk Marginal I'Mose Failure W fame"
Yam Mac pnnb cnnmton may nsun In harm ad"Monetary antl [remel Women Mi.
Mee mMMine donshwetarngwnW ROEMt 1. 06mmme
r MIN the someone of any cerswal proPody,or other tong of value arrich ary person string Mlex Or any family mamba of the
ManuelvnehG to preserve. PineWex CrerMtfium
is not rmganaige Mtie removal of PorsMel iWms fivn Me wnbinerd M1om MB Rmairs of Me OacGeed. Personal Mma ynln Me
co�rfM_IM�r OfwIIM1 MB nnWnewlllMdeeboyeO by Necmnatlon pmcaaant GnnotMre4lewtl afaruematlon.
rtia Imo Mreby auMoM Plr lv cmmmnum
W C`mnJvte Ma mmalnB Ol Me Mcaretl.
FINAL USMSRWN
The Porten autad to ro "Ma aen Ism m ad Metl%MGE Wkb Me nFMtdyie:
Name: RCLerf I. � mm
AMr"S. ]Shaman Arenue, Cmikh NY 1280 PMy. (518)ima9 g5
the cremate] mMlns of ceMased Mn M dy[ Na fdlon:
Runs in Cal Rum Cemetery
If Many reason Me person named eMre Gss net Wks posGom RMe vanelet remNl,
Plnewi CremaMlum wautl WWyamp"wekno
Me remalnsW Oemmx Fur"Y HmM,IPoe bytltliwy
It Gaon a Wr sided mail. m...aw..w
TMrea C. Bekm
ShimonosekiWS-W fenw.MIS) PaG2of3
Authorization for Cremation and Disposition
w /yJme7wax�
ifft unders arsifuel if Me remains are mrdaimeC 1120 Wye daem9b.Yl.
PirrrNx Cramaonum mrytispcfed Cerem.ilm In
mir,00,"i
an ilremevade manner, wen as W x nN
cftgmu !comaalERNRX
� //G ONE of Me Absoni
X ;w um W wel as consumer Vmy/co^emd}}M n mim nee been pucM1ael MmPsmore FXMI HMO. lnc.
andismiscom Naebllieks, L � Li'.a me alp\ LA �yLli
WJe undereend men if Me um Is mo email to met Me m m=mM tamable. an rNitiarel al commenr MR W Mass for dayuery
_An um is ndydpuNuaW. IMIa uMerdaW tlW tlroum Ia plyddea]adnevaee pwMbE
PireWea Cremasonum a0 plays Me clemusM moans In
puneriwi
a nest lempmary coManer W ddlvery.
Thes AWAorhallon Form ase povlME b/ a�NI- pv++'�-rar4 Was OeMed an
Densmore Funeral Hama. Inc.
Sb Alallre,Canaan. NY 1281 a�.vrwnaen
and re agred by Ms funeral chador as rnhmN no ge evecufm �
Me ha.'e rxau2d a connected copy of my AUMor mFarm.
W Re accuracy said UTPebness d MelW sayboar Islam Me nbnmratlon coddnad s)in central of dim ClY11AWpl/IIIbn Formed auNOMfs) fampooing.
Sli mN 319 Wyof May �Bdp �p
Ocrome, L Baker
W Hanisnurg awd Stony Cmk, NY 12878
WITNESS: Marmmmnm) ��
ITNHeart I Densmore
�mfo
1e Tmmn C. BMr
aem. �e
DOStAID-flaev. C8i Payal