Gleason, Violet Jean (2) Pine View Cemetery & Crematorium
Quaker Road
Queensburyl NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: 601ML F� . _ RETURN TIME:
DATE S TIME REMAINS ARRIVED AT CREMATORY: Wil A 1Cqffn
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
CGL" BLfd✓.o
NAME: vvlI+ etffA` I / '1CASES 1) 9 _I I/�
TYPE OF CONTAINER: CNN�.W Aµl6d W R� Fleµp 340
PLACE OF DEATH: wol WA &it, KBSd i GDN.I
ESTIMATED WEIGHT OF REMAINS A CONTAINER x6 ar
PLACED IN HOLM:
PLACED IN REFRIGERATION: Z./M
DATE OF CREMATION: � /O/V g GUA
TIME STARTED: 1' yp T IME COMPLETED: T "sF/V /
PLACED IN RETORT: 7'3sAM MOVED: #.MAi'I. P'YERn � 4'mAY1
RETORT A IN WHICH REMAINS WERE CREMATED: QuiA- MI47
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY: ---
NOTE: THE CREMATION LOG SHALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
It
,Authorization for [remotion and Disposition pm vowle;d
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MM Auf alion Form meet be comp nthsign�pdor M deiivary ofnzwnming for onm m.
Date: LIS'90 Number 715
Crematory Name: Pie VI
EW Crematory
Mew' Quaker Road, Queenshury, New YOA 13804 Phone: 518 745414TT
CREMATION 15 AN IRREVERSIBLE AND FINAL PROCESS.
Cremation Is carried out by Placing the remains of the deceased and the container holding the remains into a
cmation chamberwherethey are subjected to intense heat and flame.The heat and flallrc will iminmate add
me
are hiMexceptboneandmewl,whkhareallthat Milne IAaftercremation.
Following n , the crematory will take reasonable efforts to not the remains and other material From the
mation chamber. but some minimal dust and residue wJl likely he kR 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. CmmMW
mains generally are"u zW until ro single hagmmt Is rewgnlvble As skeleUl dam.
OPENING OF CONTAINER
The crematory may only open the container holding the umcremated human remains In limited drcumstances, such as to
confirm the identity 0f the deceased or to ensure that no material Is enclosed which might Injure employees or damage
crematory Property. If human monains amdOmv in a containerwhich is nR whable far Cremation sixth as a cernamonelAt
rental Mske ,*av Mory will rewire that Me remans be moved Into a sulrable Container before It accepts the remains. The
opening of a container or the transfer or removal of remains will be conducted before a witness and will be done in privets,
with dignity and respect.
IDENTIFICATION OF DECEASED /�
Name of Deceased: Uetco F �Gd,JF �LNN3 a.J /+ MarRlSte . //0M .
Last Known Atldrem: / Zle W _ /y\/ 0V. z U> 0Car; 1 ul
Place of oealh: a\rt� ) ZPOV
Seat: oM YF age: DOB�I� C, Oeteol Death: (Q y ]D ESBmated Weight i,SpY
Description of raskeVmntalner In which remains will be delivered
CimniagatedC dbo tl Box with Phrefifind5 k MildhilA38W8
PERSON IN CANTROL OF DISPOSITION
Fersonis) In central of disposition, initial ONE of the fallowing)
I am/We are the designated agent of the deceased designated in a will or written Instrument executed pursuant to Public
Health Law section 4201.
OR I'
(/p Y I/We have no knowledge that the deceased ex aculetl a written in l ument punuam Oo Public Health Law section 0303 or
will Containing directions for the disposition of his or her remains and jContimed next pager) /J
mssexulaev.clu i m zmawwa M 203
` I am/we are the person(s) having priority under Public Health Law section 4201 and havelM calla ro authwlre cremation
of the remains of the deceased.MW/ r relationship M the downed Is as Mlow :
amhrtfrem Her list show) II //
Numb 2— ce er. acdpton MJ B ii
A person desi in wril coherent to Public Health Law section 4201 (3),
2. The survlvllg Opens
u wng domestic Ammer
3. Any surviving Mild eighteen years of age or older,
A Asurim Ng parent.
5. A surviving abling eighteen years of age or enter;
g. A lawfully appointed guardian;
T. Any person(s)eighteen years of age or older en Wed to share in the estate and who Were caused in
relationship a the deceased:
g. A duly appointed fiduciary of Me estate;
9. A close fiend or relative who has exem W a"Uen statement pumuant M Public He Mh Law §4201M;
10. A chief fiaral officer of a county or a public administrator appointed pursuant to Me Surrcgale's Court
Procedure Act:
10a.Any other Person who is acting on behalf of the recessed ON who has executed a written statement pursuant
a Public Health Law§4201(7).
Llnldel 4LL THREE of thefink yl
(44 lMe hereby affirm That the body of the deceased does not contain a battery, battery pack power cell, radioactive
Implant, or cadioactive device and that any such materials were removed prior o the execution of this Authorization Form.
Fai�lure�to remove these Items prior to amra use mey result in hecm To the crematory ant crematory personnel.
)/rd VAR hereby affirm that instructions have been given to ov,,cammxmel Casio PafleMp141M repaMing the
removal of any personal propeM or other thing of value which any person signing below or any family member of the deceased
wishes to preserve. lve.mwwwEo Pine view Crematory is notresponsible for removal of Personal
Henry from the container or from the remains of the conceded. Personal Nam;IM In the container or wilt the Hanson will be
destroyed by M chromosome process; ro bes and ute re rawa d aftercrematbn.
yt4� lMe hereby auMwlxe lormmvrv^rnp pine Yew cremarory to cremate the remains of
Me command.
NWOMOMPTION
The person authorized to receive Me cremated remains of Me deceased from the thermal is'.
Name Baker FuneralH Pecal
Addreass; 11 HadoweefteSmenst. Queemmurry, Mail York 12844 Phone'. (518)761-WO
The cremated remains of deceased will be disposed of as slaws.
Rearm a family a per Retail
If For any reason Me person named above does not take possession 0 Me cremated remains,
a
Iwwandyo.nrol P'ne Yew Cremaary authorized a e give personal of the rerre sa
I/mnaiv.,v p Baker Funeral Home by Regal In Person or by registered mail.
U. S Cbb �
rcsusar-i lan'.m/wl wmhypremN M1FZ✓3
„ r ajtt II Mefollowing)
A4k INJs understand that it the remains are not diimal within lzo days W cremation,
lawmemy may disease of Me remains in an Irretrievable manner,
such as by scadedng.
CREMATION CONTAINERNRN
Inds ONE of thefdowmar
An urn M be used As a consider for the cremated remains has been pulchasetl from Baker
Funeral Home and is described as follows'
Maps understand Mat itthe um is too amall0 hold Me enfire comatetl remains, an atltlxgnal rigid container nay be used
for delrvely.
TrOR``-LL
rya An um has rmt yet been purchased. INde undertand Mat if no um is purchased orofnerw:se provided n wws v,
nail P'na Yew Cremarory will place ore cremated remains in a rigid temporary
container for delivery.
This Authorization Form was provided bypnraenmdnaTl Gala Raflem xlaad0
was executed M xv�hI,w a Baker Funera Home
S,,wnomeexoW 11 La N Y 1 and s sgne! by the funerel daces
as waowss to xs executm,
IM@ have rerelvM a completed MR of MIS AuMcnzadon Form.
The person(s) identhed below Were the pears sl in coned ofdisposi(ion, was by sharing MIS Au(horizatlon
Form, affoo(s) to the accuracy and camplefeeryss offt in(mnae'on contained in Mis Autlwlizabon Form and
sutmrize(s) the saregdno.
Signedthis Sl (nstay of U.J ff
Slow,
l2IoV 42102. Gl Usr",t Aoryuf 1I✓ 1z8dy
aiwe rb.n_
WITNESS: ^ n
Coal RaReM
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Funi Home RM. x01130
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