Seeley, Vivian Rosemary Pine View Cemetery g Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: _
_.._..__.AgNotbo _..--- ...._.__.__ _.._ RETURN TIME
_
DATE 8 TIME
REMAINS ARRIVED 4T CREMATORY - -
NAME OF FUNERAL DIRECTOR OR REGRISTEREO RESIDENT DELIVERING 7-MA�_
n NG REMAINS:
BQ -
NAME -------
_ UFYyAa _ 5
TYPE OF CONTAINER ---CASE p /a
F�PLACE OF DEATH: I+E_ /• �y
m�J�AI4
ESTIMATED WEIGHT ---'---'OF REMAINS 8 CONTAINER_
PLACED IN HOLD.. _ - -
PLACED IN REFRIGERATION:
DATE OF CREMATION: ZH -_'---
blyh0
TIME STARTED: "- .
IO,)5 —�� -3 '-'--
.- TIME COMPLETED, L'G�n
PLACED IN RETORT: __ ryry 1
I0 WERE
MOVED:
RETORT -'-'-
p IN WHICH REMAINS WERE CREMATED;
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN qB HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION IDC SHALL of gETpiNEo IN THE PERMANENT FILE OF THE
New York State
Depart nt a State
EWYORK I Division of OrvT`IO^OF Xirivit IFS
sTATyoF (g.C1:"e:n:r,
TY Cemeteries near
nc(510 e7e6226
Authorization for Cremation and Disposition
This Au rametanon Farm meet be Completed and stem.prier W deliWq Mremama for mmo0on.
Dots. 6 - ; - ;l;`L Number: -70 1
Cummanorywaks. Pine Vlex CrMMpdgSUM
Addreas: Quaker Road Queensbul NY 12806 Phone: (518)745-0017
CREMATION 18 AN IRBEYERSIBLE AND FINAL PROCESS.
Crystal Is waled out by placirptlre remains W the dew and the container holding the remains into a mmetbn MambrMm
they are imported to intense heat and flame.The heat and flame will Incinerate and consume eveMhing except WM and metal,
which am all that will be left abr demanded.
Following crereadcon,Me Crematory well take reasonable Wells to remaW all 0l Me remains and other metteel from Me model
ream bn but scene minimal dust and residue well likely be kfl behind The crematory MII aepmale InGtlenbl and foreign mat Wfrom
Me remains and Me l reduced and foreign maganal tell be disposed of asMuiree Wlaw.The cremated remains evil be nwcbeniplry
embedded into smal pieces and placed mto a eetignatee container cr me,Cmmabd remains gerarallym pulwdzae agent no
slob fragment in recagnlrable as SW lduos.
OPENING OF THE CONTNNER
meneryidenlrym re"Met no mmenalis endowed whamargniinryn employees chemical
damage n ryy such Noto m'Inrm X
No top fim
human Mnalm am dtlNered Ina container which IS Not uibble for cmmWan such as commodity or rentals Me
eel will damages Nat the mmalns be moved into suitable contalrwr before It accepts Me remains.The opening a
wnammer or the banal or removal of remains mil be conducted Moore a witness and will be done In pMary, wflh dignify and msoom
IOENTIFICAIDON OF DECEASED
Nameofoemawd: V"ven Roseman Seeley mai l5 tus: Widowed
Lastxnewnandival 152Sherman St., Glens Falls NY 12KI
plawof0eath: Glens Fells Center, 152 Shem nAve. QueemWry NY I
Sn:O M Q F Age: N DOB'. o l� DetestO : OSKh 020 Estimated Weight: r"
Desorption of complemental In whi Nobel wfII he royal
M . PrL- aces G-Sjcel LSO. CfG)M� d h-a-A Cade_-
PERSONINCONTROLOFDISPOSITION Pill w Cd OO uQ tr4own)
(Porsm(s)Mcoming?WdrepwYim.=NONETtM rsirq)
amNJe ere Me designated agent alone deceased designated in a well Israeli InsotxmM Mewled purtWm b Pudic
Health ter,5atlion 4201.
-0R
Il have no knowledge the the deceased executed a eMtlen tenderedfragment t0 Pr is Heats tees Section 42010ra
kntaening dbecllong for the disarranged of his or Mr remains and grow are the person(s) hav,rg pnmily,under Public Heats LW
SeNon a201 and have the right to Neither eventalian W Me remains Of the deceased shown relatlomhlP W Na deeweed Is w
follows:
Vivian Rosemary Seeley
N"m done,ww
DOS.18p84(For 08115) Pope a2
Authorization for Cremation and Disposition
nnaandrum lm me refuel
Number. 3 Descripron� hl
1. A pemon designated in wilting pumuamla Public Heats Lax section 42o+(J):
2. The surming spouse:
2e. The surviving domestic partner,
3. Any surviving cull eighteen of of pa or Oder;
a. Aforward bahou
5. AsuMWng siitrimmed years of age or Oderl
IL Ala lh appointed guardian:
T. Any peraonnoeighteen years of age or Oder entitled to sham in the esmM and and l✓ m Goaetl in rebtlMshlp to the detmeed:
r. Aduly appointed(iduciary of the estate;
g. A arse blend or relative who has vented a wrinensretoment pursuant to Public Health tow 3edbM201m;
10. A chat fiscal officer of a county or a public administrator appointed pumoant to the 5unogate's Court Prcmdum Act;
Her Any other persona is acting on behalf of Me deceased and who half fmdPd a Mftn sOmt nt Wrsuanl to Public Hwlm
Low Section 4201
�(�(I�yi nAALL THREE of the bMvnrg)
�Lyr=IAce famous afire that Me body of Me deceased does not enter a bedery,Cabery,pack power fall, n di dioave implant,
Yor undeaglve dome and that any such maRrels were mmov N prior to the emwtion of this AUMotl aN ft Farm. Failure Ad mnove
M»e/Name War cm aUon may mull In harm to the emmabry antl�cmna"personnel.
OUL�I(�. 'J IM1Ne¢firm Net lnsWemems hive been green to / � � If �
regamiN me mmwal M eat personal propeM or ether ming of value At& arty Penton signing uela or any limits member M Me
deceased Msbs to pnywhor Pine rennatomen
Is not responsible for the removed OfPersonal dents Pm the core a'mer or form the rerNNs of me dewaM ,PBnonal IMme Its Inits
container or wW rim mmalad will be destroyed by me cnmadon pdcaaa and cannot be M eved afro ommNon.
—IM&hereby sutrund Plne Ylew C!@ rorium
M dmnam the remains of Me deceased. rw.wr r
FINAL DISPOSITION
eTh y oo /eau no de bremlveme Tatedremalm{ofineedde edhom Meeaemah�c/ry�is
Noma'. l m I L Y EIO�f �m l FA
Address. / /)l t4r rPC llu.�4ct(7"' S)� 7V) ' b/2U3
The«e,{mmeted mmeinls of deill be/disposed of as Wio :: r y ( I
fbtaie 1 /Mc iIOSS w gyni
if day am lesson the persm named above does rot mae pmsembn Of Me mmains.
Pine vier Cmmafonum isaumoriu win po onof
veremamsto G F bva%+ery
in Masan or by replshmad mail. nrnsxrmu
Vivian Rosemary Seeley
COS181(Rw, a8115) nx++x�� Page 2 of
Authorization for Cremation and Disposition
ll�Ir,Iltie�l Me Mowing)
W V 11 [ANe undeMand Nat tithe remains are net Morned within 120 days of memation,
Pine Vidw CramabnuT may dispose of Me nmainsh
an irretriwaMa manner sicL as by sunning. pmyr,
CREMATION CONTAINERNRN
An um M be used as mnklner for Me vemsW remains hews Sean Wrcnase l th m
and ie tlesul0edasbllaxa:
IWO orwenland that tithe um Is ass amen b hold the antra Cmmaled remains,an acklmonal rigid aMtalrer may ad uaw for Ideal
oR-
Muteisnotanpucfeaed. Me understand that n he min is puNleuO ar addreiss plovNed
Pine View Crematorium wall pew Me uemated remelts In
e rigid hereditary mrteinerbr delNery
This AUNoadmition Form was Promised]by VJ✓1 � ' /V ) K-dew weseaeculetl al
�erN w
Cark[on Funeul Home Inc.
Within St P. O. Box 8] Hudson Falls, NY 13039
and is vaned by the brand director seaminess to as execution.
Meha"r Nedacompaeletl Wpyol Nis AUMaz$Von FOrm.
TM panonls) id$nUfled batow Islam Me panonle)In control or dlspaeltlon,who by aligning Mls AUMarhatlan Rom , althea)
bMa WmUl W y and complehmw of Me Informafian conYlmd In the Authorization Form and auMwhe(s)IM hard alre.
&pied Ml @ dew o/ June M 20 y
yts
�1 � d Nhe�eb sb rr�, Zeo
...aon.waa_
WIrN 9: /.I�11
Vivian Rosemary Seeley
DOS1898 f Fev.0 115) Page 3 of 3