Shanks, Betty Ruth Pine View Cemetery 8 Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: _ 11 Y[�I
_ RETURN TIME:
DATE B TIME REMAINS ARRIVED AT CREMATORY'
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REM
AINS-
NAME: —._.
_—CASE q LM1_,_}_
TYPE OF CONTAINER: LIt.AY Y.. L _
PLACE OF DEATH:
mot
ESTIMATED WEIGHT OF REMAINS 8 CONTAINER
PLACED IN HOLD:
PLACED IN REFRIGERATION: __
DATE OF CREMATION:
TIME STARTED:
COMPLETED: _�0 :3 IAIn
PLACED IN RETORT: 7.)O `FW
__..__.__ - Pr1 -_MOVED:
RETORT b IN WHICH REMAINS WERE CREMATED: _ ___
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS 1 'I
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SHALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
Dewdm.rm mspta
NV. Y ftK plvlslon of DIVISpN OF SkimmCEMETERRIIU
STREOF One Gmmerce Plaza
r.
Y 12
OPPORNHR'I. Cemeteries sir Genoa
ew (transept
As l
Authorization for Cremation and Disposition
This Aurlwrhatlon Form must be complabtl and signed Prior m Ne work 0 remains for capital
Dale:May 18. =0 Number: 60
Control Nand Fine Yens Crematory
Address,21 Quaker Road Due trabury.New York 12804 Phone: 518-74 TT
CNeMATION IS AN IRREVERSIBLE AND FINK PROCESS.
Cremation is mmed out W placing the remains of the aerosol and the container balding the remains into a Cremation chamberwM1me
t vewbjep Winlenwb andIWne. The hertantl flanw"I maintenance and aom mse"ry ingeXa bone and mvlal,
AM1IW are all Mat will be left after( arelfi .
FdMwiig Panel the crematory ral We reasonable drives to mmove all of Me remains and other material from Me Gematon
Pool but some minimal dust and residue All likely be IM1 craft elf The common,Oil scheme InGdental and foreign mail horn
the remains and the Iwerntal and Meign material will be disposed olw rewired by Iew. Thevamab Ml ns MIIbemeMen"'Y
WNedsed Into small pieces antl placed Into a designated mnWnerwuen. Ca oW remains generally an"warned urNl no
single fmgmsnt is recognisable as assured Bnw.
OPENING OF THE CONTAINER
The IXemMory may only own the container halmig the unsmnaled human vaccine in limited circumstances, such as to confirm the
i0emry of Me decea¢ed or to ensure then no maledal is enclosed which might Injure employees or Mal Me Corral parody If
human rtmalna are deliveretl I In a consumer which is me suitable for cr aeon such be centra ltl or ranfal casket,1
candmebry All consul re,WI Me residual be mavad IMo a eulsble computer before It acupts Me mans Ind. The droning bea
Parinl or tMtrerder or moral of remains All be osnduled More a witness and will ce forein m®racy, MM dignify and respell.
IDENTIFICATION OF DECEASED
Name of Decision Bety Run Bhanka Martel Blatu6'. Memho
Last knam Address:N Winds St Gle &Furs,New Yuk 12BM
Plans of Door. 53 WBInW St.Glans Page New Years 12801
$ex: ❑M DF Aga 66 DOS 4-6-1854 Date of Death 51420hl Estinael Weght ISO
DesmpAan of wskegwnla er in which remains vital be delivered.
Fbrenm Cal ptyxoM amgasd derdbwN omMinerPERSON IN '
OBTON
prone an inn a disposal mitrel ONE of the bWwlrgdI
I emMY me the dMgnated agent of the dRasetl designated In a will or written Ineirment eweMW pursuant to PUMA
Heald taw Section a201.
-0RI
yet Overall
INIe directions
no knowledge MpteMat Mf renewed ell exceeded a wwareainsWmem mutualms)hav m Public Heats Law SectionHion Lea ore
Allmon A201 red have e hard
tliswehrone cremation
aMr remalneand fore areeceased s)M1av'Ing money under Public HeaI1M1 Law
Sectlona20t end M1eae Ma ngM W submarine Oema4dn ofMe remainaMNe dKea¢ed. MylOu/eNNaneM1ip b Me tlewea[d Is as
follavn: Betly RuM Seems
Page 1 M2
DOS 18981(Ree aBI15J
Authoriration for Cremation and Disposition
In ne�bxoary
" all understand thistlM0 erosion are not tlaimeE Wtlrvn 120 on"General
Pine Vlex Crematory may Eicpue NMa ntreina'm
oo
several remain,such aw by vulla'Lq.
CREMATION COMTAIRERNRM
formal ONE dtlre monthly)
M um to ba used as a container for the monaleo remains M1n been purchased"in M. B. Goal Fu^enl Nome
and is avaib0d as follows'
IMY undOMaM Nat RMe um is Go home M mold the satire moved real an aUdill reed mMane nay be tread W deft ry.
OR-
/W. An am ihtu.kW wrnbaeed. Inve ananbndtatdre um is lNrmhaaed aran.aawprwMea
Pine Mae Germany all place the cremated material
'
m.+.am.mn
a need lemponry container br daiupy.
The AutlroNetlo^ Farm was prowl yCake C. yarea es was executed at
M. B. olme Formal Nome aw.aamdv„.�
He Main St South Glens Fab, New York 12803 vw«wxn+e v...n
and is egrsd 4 the funeral director as whom to its monsoon�m�v
INA hum rKAWed a completed copy of tie Au Vsan Farin.
The
ire the
l In marearal of
on,arms,by
g this unessential
b to sommussry and cwnplWnwa of Me�rmatlon contained In MN RUNOAvdan Farms antl ntoiam)Meb ,cang.
Wab9.
Signed Mile 19 tay of May Tmom 20
Cliacn JoNph Shank tJ:A.f+x
55
58 WanN St. Glee FeIW, Ness Tork II&It
fannies
Asti
W NnS: 1.�
Clain C. Ko (0_ . ,-_. f l`, TO ta�rY�
_ un
11932
n Beer Rush Shanks
Afiwa�ry
0OS-1808-f(Reo. 08115) Peept
Authorization for Cremation and Disposition
pneertdwnme hxbeWwl
xandow 2 Cesmiduch The survmng epuee.
1. Apram C¢agrehdln writing pursuant W PUNic Heats law Setlim 4201(3),
2. The wrrmna spnse'.
ta. The summing Wmid"partner;
B. My surviving chNd ephteen years M age or otal
A. Asurviving pawt,
5. A survi sil eighteen years of age a oy ,,
G. Amai lly appointed gu mwu
T. Arry p¢rwnal eighteen years Of age or older erahed to shore in the estate and who islare clamet in relxions pW the deceased,
S. A may appended fiduciary,Of the estate)
9. A do"Mend a rehfrve who has informal a written statement pursuant to Public Heats taw Section 02(1
10. Achiff fispl officer of a county Or a pudic admini9rator appointed pursuant to the SUrouldis s Court Procedure ACl
HIM. My other person who is acting on beheX M Me tlereasal and who has executed a written statement pursuant W Public Health
Lax Sx4on Q01M
V/GALL THREE our Me
WtlOrWrq)
% Wine he"affirm that the today of deceased tices na pMain a battery, battery di power will. readectme implant
or rWlpdiue devlM and Mtl any such matenals were removedpo'MMe asecxon added AmMatraton Fqm. FFIIUAb AmOW
tl lb SOWWcremationmaymultinharm Wthecmm=gandc aWrypersonnel.
G Mi edam Met insbudlma have been giren to Claire C, KoripMa
repard'ng the removal W am cerebral pmpeM or other Ming of value which airy person signing b&ow or any family member of the
tlettased wishes W Preserve. Pine Vim Crematory
Is not responsible fort"removal Of cenonal Xeme from Me container Dream the remain of decades POMMallhmsle infM
comainer or with Me remain well be destroyed by the cmladan proseee add mnrret be mbieved a rcremation.
Me hereby sU dm pine vwx cranatay
W cremoW m. mmwrrs arms e.c....a. a..wo,a.�
FINAL DISP0. b RtTx
The person Nhor¢ed to reUiW the mmxed remains of the d asW from Me aanatwy is'.
Name, M. B. Kilmer FuneM Home
More&&W Main St SmJM Gkrm qlb, Nex Your lM3 Phone: 518,744 110
The cremated remains of de and ad W dbpsed of as Whence:
Rebased W for husband CI'dton J. ShNs
If he am deal Me versus named above does not hake pB4es m of the mwwpdJ remains,
Pine Nex cmiWay Is autp w W Who pssevion of
vres",,miss?
W remains W M. B.Kilmer Furoral Home by delmay,
uvannnamm
W person«by rpiNered mail.
Betty Ruth $harks
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