Shelly 111, Thomas E. Pine View Cemetery 8, Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: _ __
- - - ..__ RETURN
DATE 8 TIME REMAINS ARRIVED AT CREMATORY: _
NAM ! OF FUNERAL DIRECTOR OR REGgISTEREp RESIDENT S)ZL Yf —i �Pn
DELIVERING REMAINS.NAME:
�� ]]
_C4Ep __
TYPE OF CONTAINER. ___ ppI QV
PLACE OF DEATH:
ESTIMATED WEIGHT OF REMAINS 8 CONTAINER___ ZZO
_ )1
PLACED IN HOLD: _ -"—'-
PLACED IN REFRIGERATION:
DATE OF CREMATION: -]7-202A 1L _-
___
TIME STARTED: _
-_—__TIME COMPLETED:
PLACED IN RETORT;
RETOgTpIH WHICH REMAINS WERE CRCMgTEO: S `•�Fp�-
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SHALL BE RETAMEO IN THE PERMANENT FILE OF THE CBEUATOgY
�.Apthorization for Cremation and Disposition
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ThIs ArMWaradcor Form muefb com~crear Ngasppf wdagny olrpnayra Wassersypn.
Date: J / pcve�lD Number
..s�
Cmnetorsi Name: /T/Nt JrYhl (�LrJ/h� SZt4 /
Address,/ lY4R L[,rly5(r Plene'�i�'—]�- S�ir7 �
CREMATION M AN IRREVERSIBLE AND FINAL PROCESS.
Cremation is canned cut by Flaring Me remains of Me deceased and Me container WMW the remains into a
eremmion chamber where May am subjected M intense heat and flame. The beat and flame sill incinerate and
consume everything except borer and metal, which are all MR will ba left after cremation.
Following cremation, Me crematory will take reasonable efforts of remove all of the remains and other arsenal from
the rmou tan chamber, but some minanal dust and residue will likely he an behind. The crematory will separate
adrenal and foreign material Man Me remains and Me incidental and foreign material will be disposetl of as
Mouiretl by hw. The command! remains will be mechanicalN puNer®tl into small pieces and placed into a
designated container or um. CramMetl remains generally are pulver¢etl urMl no sirlgN hapmmrt Is
recognizable as started tlasue.
OPENING OF CONTA NER
The crematory may only open Me container hdtling Me un-crennatatl hunnan remains in limited circumstances. such
as to mnfirm the Identify of the tleceased or to ensure Mat no material is enclosed wil might injure employees or
damage crematory Woeedy t human remains am delivered in a container which Is net suitable for C1rTation
such as a ornamental or rental casket, Me crematory add Moore Mat Me remaires be moved into a suNable
container before it accepts t remains. The opening of a container or Me transfer or informal of remains will has
conducted before a witness and will W done In privacy, with dignity and respecl.
IDENTIFICATION OF DECEASED
Name of DeceasM: /ryes// ' S,44 e; MCMeition s: 6)JOUtiez
Last Kaman Address: �i M1S' nY�t/ /l . 1w (srr/ h1Fn-
PlacentDeaM �CYTl+
Sex: RM OF Agar DOB: s%Nh/'4A� OeladOe l ENkretetl Weigh :
Description
/a�msketl®mMalrler In wwh�ich remains wit be deFiaretl:
PERSON IN Will OF DISP0.411I011
flowe )N oanM1d ofdwpwM1ion,al ONE of Me Idbwel
art We are the d%gnatad agent of the deceased deserted in a will or wrtfen untanned executed
pursuant M Public Health Law section 4201.
0
Me have me Mucani tie Met Me deceased executed a adjust ineturrlent pursuant M Public Heath Law
Ksact n 4201 or will containing directons M Me tlisso rimy of his or her remains art tt-mwm wi nwrlaage)
11�oosraw++ tw..mnOl eeee as
(I me Mipwlnpl
IlWeuntl€rditodifiheremalns are apt Gaimed wahin 120 days of ttemadon
rownxwi,...wl Tiu✓ins -'�th/Nf.c'��aVl may tliepoea of ih< remainsinan mandevablemannw,
suer as N amdednp.
CRENpT10N CONTp NERIURN
(NSbI ONEWtlre roWningl
An um IP ba used asa container for the crmnand renams has been pumhesed from
and is described se follows:
pVA undanfnd aV YNs um is iss anNl b hok the am ma oremeNd remain¢, an addacoad dgkI conbinef may se
usadfordelivay.
An umAhgassno[ye[beenp mead. paNe that R no um Is punlunscl or shaman,pmvidd
tow,.wr lemai /rn J-ra..i ( 'QeR aTd2uM wul prce ma casino remains In angle hani
gxeainerMeelivary. i
This ANhorzetlpe Fprm cues Pm ' a"I'All
aN aemhed a 7
ywsmm.eeua/ £ andbalp bythafuneraldlreaor
se wmmaa b tla a+enmon.
ViNe hairs mxasWetl a mmplemol copy of this Authof¢etion Foml.
Tha pNaonia) ldenpbed below ishms NN poreon(s) in eonirol of d'NPselllon, who by signing this
p omoation Form, admgs) to Ne accuracy and canPletenw of the irdormation contained in Nis
AeIUN�i�orlvNan Form arse a s) Na foropomi
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W161NaN lf►.NnW I�yy� gNaaa
I ant we are that Rarsbas) baying priority under Pubic Health law section 4201 aW Mass Me right to aabor¢e
Cemalon off remains of the deceased KidEor Ma0omhiP MMa deceased is as Mlows:
'~drop one tea brow,
Nunt0ei Oescdpfion: aQ
1.A nation
tn designated in aching Pursuant to wb Hearn Lea He yea second 4201(3);
2. The surviving source;
2a. The sundwiN domesllo Ramer,
3. Any surviving child eighteen years of We or older;
4. A surviving ParenC
g.A surviving sibling eighteen years of We or War,d.A awfuly appointed guaNlen:
T.Any Mlson(s) eghtcen years of age or oldx eMMed a share in Me estate and who 'stare closest in
relationship to Me dishearten;
g. A duy appointed fiduciary of the needs,
9.A close bond or Moline who has executed a conned statement pursunnt to Public 'R ehb law §4201(7);
10. A chief fiscal Turner of a county or a public adrriniatMor appointed pursuant to the Sumgate'e Court
Procedure AM;
10a. Any other ceduart who is andrat on bMarc of Me decreased and son has executed a wMten statement
RunueMa Public Hmkh law§4201(T).
( ALL THREE Wthe fpYwnng)
INJe hereby affirm that the body of the deceased does not contain a battery, battery peck, power pelf,
radioactive implant, or raCloarcir device and Mel any such materials were tanned prior to Me atecution of Nis
Aultgrbation Four. Failure a remove Mesa Rama Wkir to cremation may wult in harm to Me crematory and
peaonml.
IWe hereby affirm that inductions have been given to rn ✓ shoe, w T/A@R 4) An fuss
regarding Me removal of any pereonal property or other Chirp �J�lue ahiMi any 0pea!�$oonn sgnbg below a any army
memM of Me decadent wishes to Preserve. roa+xe*rmm) /%�, *.rr� G'CSn.r.a(dvc, is not
responsible for renaval of Moored bums ban Me container or from the remains of tM—� lams
Iclt in Me container or with Me nmaim add bin destroyed by Me cremation concede and cannot be retdryad
a cremation.
MVe M1erehy authorize ro.�y....t//dtJ <J [1Q(fl gJbPx4l� becramaa Me
m o1 Me
FIML OISIoCI TON ••
The person authorized to �e�y/tap Na cremated remmm of din tleonaeetl ban tMasmabry is'.
Nance: z� ,7(gm<.fFi� L y
Address PhonayU /%�.�nC/
The cremated remains M deeased will be disposed of as fol
ZL � r4 ,< y
If M any do sonA�s p m person named above does not lake possession of the crenated renaMs,
re•+aorvmma r` is �✓ /l.Qrn9�R� ce.kf'-i id auModaed roeirra ROeaesalon orua minima
rd•wmmemme 1;��N by delinary in person or by registered! well,
7,s�ri sc C rz�lz*
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