Steeley, Karen M. Pine View Cemetery 8 Crematorium
Quaker Road
Queensburyl NY 12804
(518) 745-4477 O1 (518) 745-4476
FUNERAL HOME. _-
RETURN TIME: __
DATE B TIME REMAINS ARRIVED AT CREMATORY:
sl?i.�_ LI_`lft
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
.� _--
NAME:
.- ._CASE p L�
TYPE OF CONTAINER [ � -. I GM
PLACE OF DEATH: - -
__-1LL_ r .Srwk..._-_t.____u`H�A)a"!; 17gg�
ESTIMATED ryF1pNT OF REMAINS 6 CONTAINER
PLACED IN HOLD;
PLACED IN REFRIGERATION: •u -rl1_ _
DATE OF CREMATION:
TIME STARTED: __
—..__TIME COMPLETED:
PLACED IN RETORT:
Z D11�y1 ' --
d- _—MOVED: __RETORT k IN WHICH REMAINS WERE CREMATED: Pn I(_- RT_ ((JJ � q��
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE:THE CREMA
TION LOG SHALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
Department IfState
NE' Division Of D1vlsQon OF CEMETERIES
STAi FY Ce au:
Cemeteries
"Overrun, lice474°2zs
weewdy,ounce
Authorization for Cremation and Disposition
Tnla iNFgMeWM Force mug her compotes and signed prior W delivery a remains for cdgnwon.
Greg: 05 012020 Number
Cmmab Nama. PinSV C Ma q
Adn , 21 Quallifter Rd.. Qummbury. NY 1 MCA Phone:
CRFIMTXIN 18 AN IRREVERSIBLE AND FINAL PROCESS.
Charmer is ciMed out by pleorg the rMnaiN Mthe dewased gA the mntemer hddirg me remains Into a crematiW chamber hom
May are summated tointense twat and foods. Tire nM and flame will INNNwda and cornuma everything accept W"and m 1,
which are all dust will W AR after Nove n.
FollOwirg vematlOn, the uemwyyy will take reasonable aRorb W remove all M the modems and Other material Sam me uemerpn
chamber. but same minimal dust and residue Mil likely be left behind IDecnmetcry WII w{araleIrcNeMa1 end loregn material ncm
the remains and meinutl¢Mal and Iweign maternal all W disposed Of ere npovetl by few. TM rlan remains will be Formal
pulwrizedInbsmallplecesantplawdintoadesigngdw=imrorum. Cnma mainsWenllyan WlvedWuMI1no
single fragment is rwcmmdl as skeletal tissue.
OPENING OF WE CONTAINER
The crematM may only o on the container holding the unumated human remains In Hefted circumstal such as cod"Me
identity of the deceased or to ensure that no magnet is thwlmen which might Injure employees or damage the CmmgN facri N
human remains are amend in a CO iner"iCb is net suitable fwa maX such as let ial or mMl caebm Ma
matoy will measure that the renni be moved into a suitable container m mX acc@Nmem im. fheopeningala
mnhmer or the imnsfer or Small of remains win be conducted before a whose and as he done in privacy, win dignityand reseal
OEM F CATION OF DECEABEG
Name of Geceesed: K M Shingey All sham, Never Married!
Last Known Adore . 117 River Street, Warrersell NY 12885
Plain of Death. Deceased's Resitlence, 117 River SVeet, Warrensburg, NY 12865
Sex: ❑M ® F n9e: 81 GCB. 10/1111938 Dine of Death 05I1912020 Estimated Weght 120
D pdon of oakeuwntelmr in which femams will La delivered.
New England cremation deluxe COMainer
OF DISPOSIRION
fPermv(slmxnmN OFN9pwlr, acresI ONF mare annua gl
I amide are the tlevgnaed agent of the de aced dergnmed in a will or crlowninNument evened purwant to Public
Heats Only Seaian 4201.
OR.
61) Me hen no""edge met the demawtl eveculeda written irehumend puRuentm Public Room Law Setlim 4201 Ora
will mnnmltg directions An me deposition of his Or her munina and Nwa are the puffs)hi priority under Public HmIP Law
s on42018nd Mve NengMWoutMn:ecmMStnnWNeremains Wine demesed. carom nlanmsmvmMa Mcauea leg
follow&
Karen M. Steeley
DOS-109ed(Rev. 04120) Page 1 of
Authorization for Cremation and Disposition
onsenfiommeedbemol
Number: ] DOinumn.Closest relative
1. Aperecn tlesi9natN in writing WrauanrW Public Heal0Law4eNon L2ot13I.
2. lne surviving spouse:
29. The auNwing domestic"Mer
1 Any survival red ememin years 0 ape or Oder,
C Asurvivie Wren,
5. A surviving sibling npMcen yell or age or oltlerl
s. Ale llyapWimed9uaM'an:
L Any overseas)eighteen years of age or older emitted to share In the estate and who mature rev l in relationship to the dem2md:
S. A duty
inted!fidul W Me estate
9. A close eM�eted or or slave who has executed a wren dalemanl
Wnom to Public HuaM Lax Section@op]r.
late. My ief othemuragen e a marry or bpubli of Medievasedandtor imed has executed to meanstSurreal's Court Procedure AcY
10a. My Meer personwhO is acting on behalf Mihatlecea¢ed and who has exaWedawnMnslalemenl pursuant to Public Health
ate sedlW rmryTl.
GALL THREE Other Mrowl
6IMe hereby arcum mNue early More dewued does not began a b mel atttey pi powarrell, redlox4ve Implant
or radioactive levied and Met any such matenals were normal prior to the wool of this Authorization Farm. Failure to remove
IM.e�e Tibme poor W c nrnmon may at in hems to Me cremalwy and cnmabry on persnel.
'W Inver amim Met instructions have been given M Da�viddAlexxaxnder
reaaNirg Me removal of arty pemral pmpeny or Oher deal ofvalue which any person signing below or any family member Mine
lateral ansbes M preserve. Pine View Crematory
dams responsible for the removal of pereorelihme from Me wmamer or Mom the remane Othe dawned Per IlOmsiMinthe
conlalmr or IM remains will the dnmead "a CMMs n pmcna and banned be relrlaved after cmmasion.
"'aD4We Mmby aulholze Pine View Crematory
nnxmr roCMm the remains Wine decea.l.
Iti6Wf OFT%)N4L)
avw haney aWM1onze the named funeral of tracer m Provide toy del to and cmnation by an 91 ma
are W,Htlsmd necessary In the opt neon of the funeral M rector,a no m amend the roam to provide the correct Nod and
ddress of such alternate Overal y.
FINAL DlsPosmoN
The person aNMnzed to receive Me =mated remains W Me deceased from Ma creel Is'.
Name:Alexander-Baker Funeral Home, David Alexander
Merrill 3W9 Main Street, Warrensburg NV 12885 phone: (518) 623-2065
The cnomat d remains O thorned will be disposed O The follows.
Return W family
If far any reaam that"man named above does hot Wks possession of Me co mab]remans.
Pine View Crematory is ambwiaad to give possession of
Me remalsto uAlexander-Baker Funeral Home try delivery
In person«W reglsamd marl. Karen M. Staieley
m.•awm.m
DOS1888yf(Rev Guar Pare 2 of 3
Authorization for Cremation and Disposition
(I�the rdbwyrq)
Me understand that dome remains we not aeimeE within 120 days MmmaEon.
Pine View Crematory may dispose W Me amain in
ma.no-..wmi
an irreheva]le manner,auG a by acatlexrg.
CRE W1TN3N COMAINEflNRN
hatid ONE oflhe Arai
Alexander-Baker Funeral
An um to be used as a wnlalner for the chandi l himavm has been partial from w.....e
and is described as follows:
Me understand Ma it Me um is into small to had Me arse aemebtl remaire.an additional ned container may be tame for delvey.
-0E-
�Mumlarrotytlpurtheeed. W/e uMenWd MelRroum is pumAesedwoltewceyovketl
Pine View Crematory will plow the cremated remains in
a add temporary corral er for del very. Mmxtt d
This AUOommon porn was provided by David Alexander was featured at
Alexander-Baker Funeral Home
3809 Main Street, WamenSWr0, NV 12885
and is engineer by the brami diemor as witness on its execution w
Me have real a completed copy of this AmendmNon Form.
The personal Identified balm iYare they Porsanlst in control M disposition,wre by signing a xis AUN Ow Farm.Mastro)
to the accuracy and complebreae of the rnbrm Mon ca mainsed In Mis AUMorrsaa'on Form and eWharibishi Me rorpaing.
signed Mle 201h day of May ,30 20
David A. Mastro
7 Carroll Lane New Pal NV 12W1
W ESS:
David Alexander
Row rwmvnmuxw w.
10034
Karen M. Steeley
w.uo®m
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