Cormie, T. Joyce Ito,
Plne VIEW Cemetery a, Crematorium
Quaker Road
Queensbury, NV 12804
(518) 745-4477 or (518) 745-4478
FUNERAL HOME: __Cy],,L) _ _ -
---._ _. ._ RETURN TIME 4A__ _.
DATE A TIME REMAINS ARRIVED AT CREMATORY: - ism
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS.
NAME: �
_. _.__� 4 .LD�le
TY E OF CONTAINER - '---CARE p G 9 /rwt-s.w-.L p1A ,!.aS C+s(1al-.CQ C[reAA1jA,.�Gs�C_[SAP-1-b�
PLACE OF DEATH;
441
ESTIMATED WEIGHT OF REMAINS B CONTAINER_ 1bS
PLACED IN HOLD: _
PLACED IN REFRIGERATION:
DATE OF CREMATION:
TIME STARTED: —Q
_TIME COMPLETED; 3
PLACED IN RETORT: ._
_. MOVED: -1 8��e1'�,
RETORT IN WHICH REMAINS WERE CREMATED:
_ _ aK '7
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED FROM TIME Of ACCEPTED DELIVERY: MORE THAN 48 HOURS
NOTE: THE CREMATION LOp SHALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
York State
Depanem of sure
NIIYYONK Division of DIVISION OFCEMOm rcETER1E5
4ATEOi ` a99WIA119unArrtnw
OPPORNNITy. Cemeteries yp,Ny 1333, 0001
TebpFme'.1518l Oait06
Authorization for Cremation and Disposition
Tnlc AudmHmWn Fomr mart M 0omplmrl and signed Fluor to eenvery of remains 1a.cremadon.
Date. !11 JA 2020 Number d&I
Crentrato rro: pine V'mw Cramatanum
Atldition. Quaker Road Quitanni NY 12804 prom: (518)7454477
CREMATION IS AN IRREWMISLE AND FINAL PROCESS.
Cremal is ormad out by ganrgi Me mansion of Me deceased and the wMeuner lidding the remains into a v ollm chamberwMre
May are stage ed to Inner hear and tame.The beat and dame wi111 net nenh end consume everyNlre except bons and mail,
wM[M1 are all that will as 1M grow rnmadon.
Following aversion,the crematory will Like reesona We eft no to remove all of Me remains and oth er materiel Man the cremation
chamber. but Some minimal dust and residue will likely be left behind.The crematory all generate incidental and foreign rnNeriel ham
the remains and Me Inddental and foreign material"it be disposed of as normal by law.The cremated remains will be mechen'ralH
pulverized into emNl pleme and plated Into a designated container or um.CmmOWr aim generally are pulverized until[am
Single fregmem in maogniaabF as Sm Aral wee..
OPENING OF THE CONTAINER
Tile crematory yoyon eopenl container facing Me umaemi human remains in limfted clrmrndenws. such es So confim HAS
dent"the deceaud or to ensure Nat no mail is endosed which might Injure employee or damage the dwm"pmpaM.N
human rimer no am del Hared In a carriers which Is not suitable ter rnmadon such an wremonlal or rental wsbt,Ed
dark start will waulre Met Man moral he as moved Into a suitable Paul her bebm It aaepN He remains.The opening of a
wntainer or the transfer Or removal of remains all be bond Wool more a witness and win be time In priary,wT dignity aid reaped
IDENTIFICATION OF DECEASED
NameNDa Bee T, .OyceCOi Marital Statue'. Widen
Lase KnownAddress: 19 Led Dme Lake Ginforme, NY 12045
Flawof0eem: Glens Falls Hospital, 100 Park St., Glens Falls NY it" —a�'1�
Sv-QMQF Ape'. ME 008, lnCR/1933 IntentionalIgti ESBrmudwelow2i2266
Desorption of uekeVmnhimf In which remains will be wllksmal
PEARO IN-hew �as TICo G �ma on Caste ) 7
woc i 10atFdm
(NR 3) CONTROLadsFDtsP09ITIOO C'b �� ba Wc� '}aft
(PemmNal MpaNmddapwmm, mifieloNEarms numringl
enters are the designated agem of the deacni derigmled in of ill or wnwn insWment¢ieowd promise to Public
HiralN taw Seauan 4201
OR
Kit lMe have no knowledge that the wwawdevecutM a wrNen instrument punmm to Public Heats Law Sector 4201 or
will containing duacTmas tar the dispwition ofhis or ber remain and I/we are peal pe having traderm e under Public HM taw
saalon 4201 and have the right to aumortt cremation of the remains of the dencei history mWtlorpmp to the wessed Is as
rollawa.
T. d0ym Cprmie
005-1098-f(Rev. 08115) Pace 03
Authorization for Cremation and Disposition
nn¢ed horn Me Ad below) -I 1 1
Number: I cffibm;da � on
1. A perwn designated In wining iunuanl to Publk Hea1111 law sectlon 03010).
2 The surviving spouse;
la. The surviving domestic Mail
A n MYSurl Ong child eighteen share M age or doer
;
5. parent A¢uval sibl
ing
6. eighteen yeah old of age or er;
Al awfully appointed guardian
e. My personal)AdutyapointeighteenyyOiary f the age on older erNllee Wabere in the estate 6ntl who aloha Gwe¢I in re184omhipNthe deCaBeBP.
estate
9. ACIOse(reotl or reldafive whothas annual a frillen statement
10. A chat fowl ofirer of a man ed pu proposal to Public Healtblaw5 ourt uioM2otpp,
10e. Any other borecn who i$also or apubli of the administrator who
has
ssur the all
Public
g on behalf of the de¢e9ed end who hag BeOtubo ewMten statement purtuant to Pudi[Health
Law Section 42019).
nmGet ALL THREE of me ldlmnngl
KH WJe memory affirm that the body of the eechaaed does not contain a banary, batlary lad.powerwl radicadive implant.
or radioactive device and Mel any such material¢were removed morlo the explosion of this A✓rhdtleaYM Farm. Failure to remove
bases Named poor to cmmN on may nsutt In harm My rnmatpy and cmmalory penon�mI.
�y1 khr IMe alpha Met implan 9Mv¢been given to IHM GJ IVie/O
regaitling Me removal of any personal property Or other thing of value which any"from sgnirp bell or any Mnlry m W0me
deceaveewishe¢topre¢erve. Pine View Crematorum
IVplresponsible for the removed of personal Items from the container Or hoe the remains of Me tl%eased. PommaiMmslsaln Me
�l contalmr oration the remains will be epVoyed bythe Cnmatlon preens and cannot be mbbvee after cnmabm.
"/ KH IfNe Mrerry auMceze Pine Yew CremMatmum
WW wv
to rnmam roe nm.ins of the eewe.ed.
FINAL INSPosmoH
/
pemmT �eu vex taremlw m rern Me treamd aim of ties defended horn the colonel is:
Name: l arlyi Z:-1i -tome Spa
AWh.ea'. FRS y✓lain S� I-l-udsmsr�, Phone: 518 747 9zu3
The o-eme(l�i remains ofd sed,,s{elll�l be disposedm as bullwn:/' N' y 111
5L" i6d Pine VueuJ C�mehll
I my meson the person marred bases time col take m¢¢es¢ion dthe amend remains,
Pine View Crematorium isauM WWgWposaeaaoncf
lheremalnsto Carson Funeral Home Inc, byclowery
In person in by registi mall.
T. Joyce Connie
ma+✓ro.w
13)( S-10994(RAL W15) Pap 2MJ
Authorization for Cremation and Disposition
(IMNer Merdhi
KN Vale understand that 9 the remains are not claimed whin 120 days m crommon.
Pine View Cremainnum msydiromer offer remains in
on emotional manner, sum as by¢<anenre. mwo
CREMATION CONTMNENURN
M um to be used as a wnbiromi Me cremated remains may been purchased from
and is described as rollass'.
[Me understand Mat it Me um 41W mull to hold the entire WmNed remains an adtlNOnal rigid consumer wry he used for delivery
-OR
KN An mn is not we purchase]. Me understand Mrs if no um is puMmand or otherwise praaided
Pine View Crematonum ¢ill place Me cremated remains In
a mid temporary container for delimay
This AUModudon Form was prammew by / O/yPF � J wpexammodat
mmmomi,mew
Carleton Funeral Home Inc.
68 Main St., P. O. Box 6] Hudeon Fells NV 12838
and Is egned by the Nrearal Therm,as witness to N uecNian.
Me have waived a competed may m this Authrom goys Farm.
The Members)MerMfled allow Islam the permnlst In control MspbsMon,who by sign In In In A assumed bon Form,amWs)
to Me accurate and core elsewhere M Me NFormsYon metal nod In MIs AUMOhs n From and sutroi Me fon0bing.
3h0nyy�dMls 20 dayo) IAev 20 20 .
ICa1-h lees F� � IRe� tshauSer�YadG,_ O. ualw.sl.Ad..a.."
,wao, s:
wCs F r�wa
T Joyce Cormie
ami a�—
DOS 1803-f(Raw.W15) Pi 3 ad3