Thomas, Charles Leonard Pine View Cemetery 8: Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (818) 745-4476
FUNERALHOME: _
��'---'-- RETURN TIME: _
DATE A TIME REMAINS ARRIVED AV CREMATORY yy
NAME OFF 5(Zt�ID �'WN /FUNERAL DIRECTOR OR REGflISTFRFO IT
ESIOENT DELIVERING REMAINS:
Y_�nrMo
_--
NAME
—CASE A GS3
TYPE OF CONTAINER; _ ®
Cn w,
PLACE OF DEATH: �µ'- ' 0jllf IF
ESTIMATED WEIGHT OF REMAINS S CONTAINER
PLACED IN HOLD: ' --� 3 �bs�,nle
_.—
PLACEDIN REFRIGERATION: __
—. . _
DATE OF CREMATION- - 3,0_'f�y
TIME STARTED:
Il
- . TIME COMPLETED _� -
PLACED IN RETORT:
ETOgT ��*yIE�
XI MOVED: 7�'— �0
RETORT pIN WHICH REMAINS
WERE CREMATED; _ _
DETAILED REASON FOR DELAY IF _ �ll W=-e'k �REMAINS WERE CREMATED MORF THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SgpLL DE RETAINED IN THE PERMANENT FILE OF TNe CREMATORY,
ans move
Aut�orizotion for Cremation and Disposition ies,"mL imm,
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Thh Autllaisatl°n Form must ber comphmd mM seemed Feel M da0yerl'aw sratramatldn.
EMS. Number_ 03
Gematory Name- Pine View Crematav
Addreas: Quaker Road, Quemle Bury, New Vora 12804 Phone: 51811454477
CREMATION 15 AN IRREVERSIBLE AND FINAL PROCESS.
Cremation is yarned out by placing the remains of the deceased and the container holding the remains into a
cremation cM1amberwherethey aresubjecled to Intense heat andflame.The lint and flame all kltlmrate and comume
evervl im except bone and m L Mach are all Coal wRl be IM after n M.
Following cremation, the crematory will take reasonable efforts to remove anot the remains and other material from the
cremation chamber, but some minimal dust and residue will likely be left behind The crematory will separate incidental and
foreign material from the remains and the incidental and foreign material will be disposed of as required by law.The
cremated remains will be mechanically pulverized into small pieces and placed into a designated container or urn.Q mated
remains generally are Wlverlue until no singkfrapnent is recognizable as skeletal thee.
OPENING OF CONTAINER
The crematory may only open the container holding the ontircmated human remains In limited circumstances, such as to
confirm the memin of the doctored or to ensure that no material is enclosed whim might njure employees or damage
crematory propem. If human remsim are delFrered In a container whim is net suitable for cremation such as acarcmoMal or
rental casket,the cmnxary will require mat the remains be moved Into suitable wnminm before N accepts the remains. The
a Feel ng of a container or the transfer or removal of remains will be cold utted before a witness antl will be done In privacy,
With dignity and respect.
IDENTIFICATION OF DECEASED
Nameof0emased is 3C 1 Marital Gtalus:�(y�
Lail Known Mein Ili: I TQ(� 11�T 1
Place of Deefh- G or w J C, t�N°i?Y
Sea: * DF Age:2 DOMC55liC3/IyyO Darebfuaath: pint min estimatedweight 2CC(l s
Description of casket/container in which remains will he delivered:
Corrugated Cariftereard Box with Plowed Sta mark Model h 38808
PERSON IN CONTROL OF DISPOSITION
IPersan(5) in control of dishasi ran, initial ONE of the fallpwingl
I am/We are the designated agent of the deceased designated in a will or written instrument executed pursuant to Public
Health Use section 4201.
-OR-
I/We have no knowledge that the deceased executed a written instrument pursoam to Public Health law section 4201 or
will containing directions for the disposition of his or her remains and(Composed next page))
DS l INYA.CI -T�
Mlfi
1:05.1awLf-1 lyre Den Xmeg4aaea mi
I am/we are the persoMs) hi prorlN under Pubic Health Lawsen ion amt and nve the right to authorize cremation
of the remains of the deceased. My/wrrelanonsmp to one derasM IS es%Il w :
fmserc fmm the letheM:) / I
Number:,)--Descri stbn
A person designatetl in writing pursuant to Public Heats Law section CZ01 (3);
2 The surviving spouse;
]a.The surviving domestic partner;
3. Any surviving child eighteen years of age orolder.
0. A surviving parent
A surviving sibling eighteen Venture of age or older,
6. A werfully appointed guardian;
T. Any paceon(s)eighteen yeare of age or cider entNed to share in the estate and who share closest In
relatpnshop to the deceased;
g. A duly appointed fiduciary of the estate;
9. A close fnentl or relative who has exewted a written statement pursuant to Public Health Law§4201(7);
10. A chief fiscal officer of a County or a Public administrator appoiMetl F+muand Is the Sunogari CCU"
Procedure Act;
tOa.Any other person who is doing on Cancer of the deceasetl and who has execuaa a written statement pursuant
to PUNK Heatih Lax§4201p1.
lrnitral ALL THRECaj thefollowmp)
I/We hereby affirm that the body of the deceased does not contain a battery, battery pack power cell, radioactive
implant or radioactive device and that any such materbls were removetl prior to the exxution of this Authorization Fwm.
Failure to remove these Items pi to cremation may result in harm to the[remamry aM crematory personr:el.
I/We hereby affirm that instructions; have been given toµew:amo .,I Come eastern;#141M regarding the
terminal of any personal property or other hing of value which any person signing below or any family member of the deceased
wishes to preserve. lommmmwwa P'ne Vlew Oreirmi s not responsible for removal of personal
Icems from the confiner or from the remount of the deceased. Personal hem left to the Container or with the remalm will M
de troyed by the cremation braces antl ranrot be deViwad after meani
I/Vle hereby authority to cremate the remains of
the deceased.
FINAL D sPM TIOH
The became authmrrsed la receive the t ematetl remains of the deceasetl from me crematory Is'.
Name: Balker Funi dianne Persocamsel
Mdrese'. 11 I-egymbit Screart Questradju, New York 12004 Phone: (510) 191-9303
The cremated remains of dettaud will be dispose l of as fCllmvs:
Return to family to he deadatl
It for any reason the bersan named above doers nM take Campbell of the Canceled Comets,
fowmcwr ewrel P' Y Ga authorized to give pmaseas'mn of the remains to
lry.+e�dnmzmrel Baker Funeral Nome by delhrery in person or by resserM mail.
evi;Ml-1 • 2�S Qw, of w rise ins
' (�v')rne)otrowrovl
IMre understand Mal dMe remains are rust mMlW wend 120 days of cremation,
m.a) Pine Yew Cremehory may dispose of Me remains in an ineblevab a manner,
such as by multenng
CREMAT fON CONTAINEPNRN
roiemi oxe o)McMAowinal
_qn urn ho be used! as a container for Me cremated remains has been purchased! From Baker
Funeral Home and is descnbed as hollows:
I101fe understand Mat it Me urn is too small to hold Me entire cremated remains, an summoner rgid container may be used
Mr deliver.
-0fl
An urn has not yet been purchased have understand Mat it no urn is purchased or otherwise provided ror m tv
wm1 P"ne V'ew Crematory will place Me cremelen remains In a ngel temporary
container for delver.
This Authorization Form was provided by ywenm.envmmel Caesa Raiders,9141M
was executed at 4vxm.>*mm.mr Baker funeral Home
(smrwrrumw amema 11 Lahwelle Street Oueensburv. New York 12004 and is igned by the Macau director
as witness to its execution.
IAAM have received a completed copy of Mie Authwusatbn Farm.
The pernsiss ) MenM1Red below Were Me persons) in conbd&aispossion, who by shnizg this AUMorization
Form, Masai to the accuracy and completeness of Me inMmnairm contained in WS Authorization Farm antl
auMorrsefs) th foragoim
Signed sh4 day of
rvneo�m'nreewme
Sheldm-; #�oscorz
GIpA
WITNESS:
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FuneralH #01120
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