Tucker, Jan M Pine View Cemetery & Crematorium
Quaker Road
Queensburyl NY 12864
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: _ q n
---"— RETURN TIME:
DATE A TIME REMAINS ARRIVED AT CREMATORY: _
NAME OF FUNERAL DIRECTILO1R OR REGRISNTEERREO RESIDENT DELIVERING REMAINS:
"=L
NAME:
.__CASE #TYPE OFOF CONTAINER: _.—.,__k4 ) 4.y l
PLACE OF DEATH: ' ifs IdiS _ 'V TN7k t �r}(ryr
ESTIMATED WEIGHT OF REMAINS 8 CONTAINER_,____
PLACED IN HOLD!
PLACED IN REFRIGERATION:
DATE OF CREMATION: ---
SIL ITD
TIME STARTED: J_p� _ TIME COMPLETED:
PLACED IN RETORT: 7_4 ��pN py1
lYL__MOVED: _... g.'_�•11F4.._Q_�:1:/RETORT pIN WHICH REMAINS WERE CREMATED:
19N_FROTIME
__-..
DETAILED
REASON FOR DELAY IF REMAINS WERE CREMATE
FROM TIME OF ACCEPTED DELIVERY: D MORE THAN 68 HOURS
NOTE: THE CREMATION LOG SHALL BE RETAINED FN THE PER
MANENT FILE OF THE CpEHpiOgT.
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SewroRlc Division of DwaD Ed"EN�
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Cemeteries mN^wreArc^w
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Authorization for Cremation and Disposition
Thb.<uTMaaaon Form must as <nmrmed and signed prlw ro eeM.ry or remains for calibration,
Dee. 05I18I2020 Number
Glwlwv Name:Piro View Cremalpry
Pmma',Cueker Road pueensbuly, NY 12804 Plea: (8/8) 748d478
GILIMTION IS AN IRRMRS®LE AND FRI PROCESS.
C Wacwrt WI by p4a,g meremama d thin Michael and the wMurw holding the bowman a themati0n eMmpn w e
mw aR erAjMllo Atemeleat anM(ume The Matand Sams NOimlmM and coneums awryMly sacral bane and NO 1,
w h an all the real bin WI inner rnmadon.
FOl Mwanedcn, the moral fail latemovanable enorm rorcmon all dine remains eN Mlpr mal from Me<,ememn
tlw l. butsinemrnlmedr tandreeaueill@,Nvoe RncehFd Tlwblmeoly will xperNeIntiaenuleN krcipn mnerwl own
tlr.lem ,n env m.rnaaenral ens forego mammal rein m eiapovedaae rewil<e bylaw. the oemel rem pu vnu m meth rrellF
WranyIDtl fragment
A eiems area plasm rm a Mngn.4e Wnnine.w um. emmapd mm.ma g.mnnr .ra aumarvsM until m
ahgl.r.agmem g redognmele as axrle,l hom
OPENING OF THE CONDAMEe
Tie invasion may only open me ransomer hall tree O,c emweM human matters in Nrinl arcumavrces such as ID cMM1mr me
gamin dime aeunlwmeneum mil no mamhe Nencgaedwh<n mqe miure emeovmawaamyle the w..memry Praoertv. u
nulnan ,.m.m. a.eeh.retlin .aom,Im,wNcn I.na.aaaNr ror<ramalbn aWn w<anmome o.nme< Sn
mmews willrmulre inn ma rcmalnaamowdlmoasuybla wmaim.arw. n«<aeu m. reading. The opwrim ors
nleinr w me M1enerer or rcmovel artmmne von be mlaudl Ixb,e ex+Nem erw roll En Morn M pnvecy ^In apruts arq ,eepecl.
OENOFICRTMIN OF DECEASED
Norm WD.rea.ea'. Jan MTucka gnaw shun: WeloweE
W Nmrm Fealme: 191 Stab Rt 149, lake neor9e , NY 12M
Pyres Dam:, 191 Sbb Rt 149, lake G Me , NY 12845
Sax: ❑e OF Aqe: 49 DDa'. 10I12J1970 m dx 0511812020 smmatwregm LBS
DeeOOIMr dceixlVrmuirNr In wniM r m"adMYNhad,
Sultakl Casket Company—Alt gi nlaiMr
PIRSON IN COHiROL Or DISPOSITION
1p raorxem<ax,a of mepoSflm I re o time rwvnly
_ IVnit art the angn afire ofmis eeesdpeyu tin a van a,wrmnn innnmem aavuMl pnrsuam to Rome
NWmlPv sewon Q01
.GFILI
IM'e have no xm.Wdge mat be Cemaaell executed a w erry Mitsubishi puuenr to Public Heath t.n setlrm 4201 or
will mMelrenp Ma Me Ip me drapasnrm at has n Mr remains and man an,Me persowe he,"MOMN under Fume Heam Lan,
Reagan 4201 and have the night b aommve Mrdson of me remains of me dairies *Our nYWnshlp to As danom ed e o
gyres'.
Jan M Tiller
Dog fell(Rev. 0420) plge 1 ors
Authonbatlon for Cremation and Disposition ,
Prrwlmm�nw roawl
Mnbn.ale_ Decvgmn&Wing - Judi Framer
1. A glwl yggmed in wrong promised as PWFC HeeM lw 3etlbn lMlt3),
z Fin e«vrNgapwng,
a mesnwetaauwanwnw�
x Amearl LarN�a ebhleer�Nert a.3eaea.r.
A AgeMNp pyenl
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!. AbeMAYapwiighteuen�;
F. All,DoMmorril eighteen ismus of Ads a, renlekeb Mert in Me eslek and VM Nxe rbseel in relallmeNpblheae4and.
3. ABury hello, omn,e of the Mw.
9. A~ lren0« rekMa who has.nuts.ewnwn MemNepmenlWPWBC XeeM Low y rt 4201(7)
le. my
al pedfimda counts acmtrW e Puts:
entod Minnbabr apgxme has OXO 1a 11w 3unyFn's Cwn Prxrmo l Pa
1W. MY other 201(7on )e xlirq qi pem'pl yrpyygee]eM who Iles enorME aw>Akn eltlemenl pureueMbPutlk NYlb
Lew section aEDg11
Mandl ALL 1 REE of Ion Idummid
�� im'e naebr wNm uallro Nndv olm.a.eaeea en.mrnlkmamlun. mden wu.p«/er�f Mao«b..Nrro�nu.
or ralpxrom wxry and Ogl armaWl mekms wMeremws,prq on he eaeWm d the A Hmalbn Fprm. FYlue b mwre
aside is' wl«bcmulkn m3 muNN NrmbtlN uMp41ry anU mmel«ywmrml.
11=NYe elRmllm nlYruann naux eem prvenm _ Mesh J. Iteblmpia
MS.Mia esn nnn.>I angY eng.ena prespMn«am Mga.waaNM wry when NweN blevpraNaaay mngapraw
daengad wbhngbatwn. Piny Cnma.a
Ia sal re.P«n.Ge krme nnin wrea+a ma Nun Me«maar«Ndnu,e rtme�du.angasngd. Ptnarul llngla M in tins
eomaw Of wW MG sell NCandidate!bytlw considbn presents and cannot b MnrvM after cmmmeh,
5 _nareanNar.NMdaa Pine Vim Crean; y _
,r19` to cr am ask mmaim of the assistant
aw Immense suuoM tit denW lunenl ambr b Promida to, dadmis b and enmMon In an alkman
Mdrs o1�ucM1rms!,e[emainyiorydis opinion of met fsnntldiron«. and b amend does room to Pmae Mn eonM name and
MN paPO3n1ON
R Indoor automated in aerobe ones w«m.d mwn a w dsuup Nan Ma pwnry is
Na«e.Jptll Founder
Address 123 HIMon Splashes Rd. PUMem bbODn NY 12551 Phan: (518)9554007
Tut mission.mina decrease"an deposited ding Naess�
Retunt b Me famiN for W"
nla tm maw doe pangnnanad aeove.--. meow wng.nganaM.aennbe mow. - _ _�
%m VMw Cremalrxy bMaimngdb3M pmwnga
w nmwb Repo^ DenM blaflgrtl Fun3resl Nome bYdaMnY
p..rrn..n...
In passed in M repianae now. Jan M Tucker
00&13G&I(IW. DNIDI hps 2 a3
Aulhorluition for Cremation and Disposition
f�xm.Mbe:ror
J� vmeueemamee M.INMe imee.in..nmmknd.M.etm aer•ammman.
Rise Vbw cmmatary mwae"es wme medm in
.n �mmenae memn, .maces M eneerag.
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nn;r;ar owc a me fnxanrel
Mum to Mevd n.mdelrnfmtlnaemWdeeman Neeenn"den.a r�ee Regan Denny SMnwtl Funeral
sacs ddeea�lmd as dnd'M
nhNe ummalmee rl,.n a Ina i.n a me asset n Ida ue ema wnuee nmlYnF.n eeeeonN rqa mrlrYrcr rruF ee wa roe asFaF.
-OR-
Vises ctsteralery enlistees"CmWM terminate
pe�aneurl
B rNNnTnWrW fM1eYMrMbMMy.
TNsawwv awt Famines FldvieeNM Mark J. Dosmeone maaexede
Ream Danny SMama Funeral Home
53 Quaker RoeJ,OueeruCury, NY 1280a
end em egnee wee M1.ertlyrgYnvkrmac m as e.eoam��
IM1ve na a re¢rvea a cwryMleC mq Ntoio Auewnaaeon Form.
Tse nnnn(e)serMfiea eelw Wen Me PnmlU in "noted of dhpmnan.xTo w elin4q seem Iue zmlksn Form,essential
to Me accuracy ere umpMYeew ofMsaoreMbn corhkna In Mb AuNahMn Form eM eWvhep)Mekuepdkq.
apnea Mem 1aM seyd Mry ,al 20 . �f
JOIJi Fieeler dru' (�e st . 'T/arnLa�s
123 Hutton Square RE P"am Sbibn NY 12Wl-
Meet
WIIaEea: N�
Mark J. DaSimane
10gtg
Jan M Turaer
en.w�m
WS1Nulaay.nWJo) PW3N3