Johnsen, George I i'me Vlew Cemetery 8: Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME:
_.__.._ RETURN TIME: _qMP. _„_--
DATE 8 TIME gEMA1H3 ARRIVED AT CREMATORY,
NAME OF FUNERAL DIRECTOR OR REGRIGTERED RESIDENT DELIVERINGtah NS
REMAINS: .
NAME
TYPE OF CONTAINER: - - .—CASE p
PLACE OF DEATH: .____
BNp,FII
ESTIMATED WEIGHT OF REMAINS S CONTAINER,
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION: �-
TIME STARTED:
__.__TIME COMPLETED: Z)W�
PLACED IN RETORT:
= —MOVED: __ „
RETORT # IN WHICH REMAINS WERE CREMATED; _ l ,�Ll 7"YD&
t
it
DETAILED REASON FOR DELAY IF REMAINS RAr— .
WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE.THE CREMATION LOG SHALL EE RETAINED iM THE PERMANENT FILE OF THE CREMATORY p qT
New York ams,
�EW voRK I Division of D P m mmPMgmm
SI g, ` DMSION OF CEMLTEINFS
OPPONFUNRY. Cemeteries WsshXrgbnAren e
l 3fiSNt
wrvdoster
Authonzatlon for Cremation and DlSposition
Then quthanv^tlo Form meet W CamplaW and wgnaa PnOr on aNivery Of remain.(w crem"CM
Data: Jig'KAW Number
Crematory Name: IOC VIEW C.IaMa Marine
». Ouaker
Addre Rwtl, pweneCury, NT 13806 516]15fa]]
rocne'.
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation is aimed OW by Placing Me remains M the tlewaetl and Me wrtlamer adding Me remtlw into a cremation&Mm rwlaro
they are adjd]ed bintense had and tame. The Rest aM flame will ImirrrM and consume exwg1MnB a%pq Min and mesa
which am all Mat will ba left after Cromation.
reddens imnnamen the vommidery MII take reasonable efforts to nor all Of tax remains and Other maternal from the cremation
chamber but know minimal dust and residue will likely belts behind The crdnaNry all wwrate lnadenral and breign malarial from
the remains and the incidental and foreign material van be disposed of as Normal Iry law. The enervated remains will be metlammlry
pulvei into small plats and aawd into a designated wnUinn or an Cnmebdeosinspenmllyanpulveri dunUino
single hagment Is re[rgninble as SSMwmI UMuf.
OPENING
The Yemeni rray only open Its¢reamer holding too statements human remains m Imbed circumstances. so& as to common theidmtily ate der. ed Or to ensure that no material is anawM whim might inure employees or damage tM chemalpry wWnty. If
human remains are MIIwM in a venation which is not surobb Mr cremation Such as ceremonial or rtnm casket ue
wmmatp will m UIM Nat Me mmMN ba moved will a wii wmalnNb re it accepts te remains.a nremains.u. The owning as
Mamer or the vander or remmal W emam rwlJ be command atbre a witness and Sir be ore in Somary, suite cavity and mope.
IDENTIFICATION OF DECEASED
Name of Decreased Games 1. Jeaer, Meribl$M1us: Maned
Last Known Address: 17W Harper,Hit ed, Hatlby, NY 1M
Plate of Death c ra�T'�Ta t i qLt
Sea. i9ol DF Age:J(_ OOS ]NR] DeIe OIDwaM: i ZO Estimated VARA:��
Davergecn Mu kW=m ner N whrJo nemeim Sell by"Name
MacA aid CmUirer mi trenNlgnwnlyrpn'CBN4Vrm-miMaar
PERSON IN CONTROL OF DISPOSITION
(PorswHs)in v¢MM M dsPavpOn,Mrsad ONE M rM Mbrvvg)
I amMb are the designated agent M the MoeaeM deapumd in a wit arMllen intlrumwt eve WWmwttO Pudic
He hLew Sadden Q01.
-OR-
Fb� � INActio Mr terests MedastMMMe tlettaydexacurfeed marsan wownatin Me penverms ill PosMoor undereafth Law Section
meaft 6La ore
MIIsonleiningnd have terse tlispwitlMe,Msenive eosins end IMnemecds . MOuing Wortsunder Me Heats lbw
Swdon 0201 and M1rve Me right b eNFunza oerrelY n OF Me remeiv MVre decades. MylOur relationship b W tleceaeetl is as
Mlwa'.
George I.Johnsen
rhawkwever
DOS-lM4(Rer.OM15) Page 1 of 3
Authorization for Cremation and Disposition
(leftlerrerabormem
5✓ Wh uneeralaM Nat are remains as net Narrow arms lzo eep dvemetlm.
Pine Nea Crematory
m.aav � may dhoome of me barriers in
en Irremeveple manner, wcn as by siallerirg.
CREMATIONCONTAINFIVURIN
_
(L@I ONE NIM Warring)
An um to be them as a nonlinear"a aemeted remands has been purchased Man
and Is eeambee as rouses:
INJe understand mat It the um is No smmi0 Wid me attire uemand remains. an intentional m ie CXMWWr mw be ame far eNNwy.
RL- T
/J An um is not yet pumNaea. IhNe undeemel that it no um is restated w othervAee Perri
PMe Vex Crematory
Pu+xn was place the cremated remains in
a role monetary wMeirrer for destroy
That AuuoriaeGw.Form wah Pmvied by PaVicia Miller wM
Brewer Funeral Home, Inc.
m ed
za Comes St r take Luzeme NY 12W
Wed is attract by me bran director as embassy to m evewtionx
IMP have et enTat a Compared Copy of mlh AumWleanon Form.
The wr (s) lm OW Wow Me panoMe)in cos"I a dumosinon, she by signing this Aumorinrion Form. songs)
m Me monetary and conpbbrwas aMe Information wnpmetl In Me AaMONntlon Farm and sutlromme)Merppolrq.
Signed Mls ( I mays Mai 20
Pqff Me Johnson
95 last Aw, LM. 10.lake Wbrme, NY 1281
WmNeeaPanama seem
fza�m aaotiwe....i vw a
(MwgeI omuen
DOS-IM)i Rau. O811 Peae3a3
Authorization for Cremation and Dispositbn -
(/e othem IN day cons )
Number 2 oecidebin: NPI
]. TMonrforl designaing ted
wndng pursuadm Public Heats Lax Searn 42o1(3):
2a. The N wing domeetk Partner'.
9. Any surviving child eighteen treaty of age an Older,
0. Aeurvrving pal
5. A surviving sibling eighteen yeah d age Or NNv;
8. A al spWided guardian;
7.
B. A Any
Perppaln)teCfitupahteen ryof eeeor dean aboard!to sharem the estate and who iWare obtainin relNumbls to the deMaedl
allure
8. gWMh'reM or rehrosewM has PC a%aten 9alumed pursuant b Public Hea1O Law Section 0201
10. ACref Mesa)Officer ofaCounty 0,a PUNIC admidNatm appointed pursuant to Me$un]at¢a Cord Procedure Act
18s. AM cancer person who is acpng on behN of the tleceaeM and who has examined a mithen aratemenr pursuant b Public Health
Law Sectone101(])-
GALL
THREE W the t ng)
VWe Mreby aflum than the body Of Me deceased done not Contain a Carl Wtlery perk, paxx Car sods W¢ Imprant,
or radihal deike and had any such redenals were removed pricrud MeexoLl Nine Autl "on Form. Falluntonmore
bridn"a 'Manor p to emmatl may Mutt In MM lc Metmnshi and cremal pmonMl.
ka7 ) Vale affirm Mat inslmCpMe have been given to PNitia Mller
regarding Me removal dany pareond proper or rater thing of value x1dM any arson NBning below any femly meant&Me
Pare New Crematory
OareaeN rdMee topreserve.
is not noconade for Me her lOf Carsond quel mm IN wnhire Oral the reasons al broadcast Pemwul lbmn lM In lM
contlimr or wiih the"sine wail be des4eyed by Ma cmmaban process and canMt be rablayed sM cremadon.
Pine New Crematory,
b 1/ IAye Mreby authorW
roexephw
m emmM the remslns 0 Me decmW.
FINAL DISPOSPION
the cerwn adbc tonuclear the mwrnled remains ofthe dewewd hmn Me Channel Is
Bmv¢r Funeml Horne, Inc.
Name'
20 Church St., lake Lucerm, NY 12M 5188g62]M
Address: per.
The cremaM MMina d dx W MII be deposed d as frAowe.
-e+kr-Mc( 40 e5 1
If Me aM Morn the person named aMv¢does nor blue pOWedon of the Uerrutled rani
Prey CeMtory
m is aMNzed to bre pnu¢semnof
the remains io Brcxer Funeml Home, Inct r Fv�xeasnunx by data"
in wmon an by ]lain mass. (i00r� I.JohMn
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