Hall, Jeffrey W. Pine View Cemetery g Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: -zkWsv '
�' +i- ._ _ RETURN TIME: e-
DATE Ir TIME REMAINS ARRIVED AT CREMATORY
ag
NAME OF FUNERAL DIRECTOR OR REGRISTERFD RESIp NT DELIVERING REMAINS:
—�
_CASE k
TYPE OF CONTAINER:
PLACE OF DEATH: --
LOL L
ESTIMATED WEIGHT OF REMAINS B CONTAINER_ 10 f
PLACED IN HOLD:
PLACED IN REFRIGERATION;--—
DATE OF CREMATION:
TIME STARTED:
INRTRT! _ _—_TIME COMPLETED;
PLACED IN RETORT:
.1
- - _MOVED: _py I'�j
RETORT p IN WHICH REMAINS WERE CREMATED:
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATEDM ORE Trygry y8 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SHALL BE RETAINE
D IN THE IEgrypryENT FILE OF THE CREMATORY.
Nhaxyllgal
NFWSTAMIOYORK Division Of olYMlos° oFc BdiEga
° "" Cemeteries ".ia`°
tea;«
radial
Authorization for Cremation and Dlsposil
This AOftN On form must to c=PlW aMsigned pal delivery of remains exacerbated.
MH1$ 3020 Number t67L
Chemical Name P're "Cr mum
Address Rl OWk«Road.Ouessamury, NY IMAM per; 151%7s&edTT
CREMATION IS AN IRIaEYE1Mi AM FINAL PRO W
Cmmapon is came] out by t eGng the names Of had depped and the Cpnla'I lwprp the remain IMc a commends dancer or
PEy are subal to lnknse meat and flame, T MandpM inci" andcomumf Sv rope ptbomaM mebl.
MWb are all MMMll be IM affair mmagon,
Fdk ngcmmm file«emal will bke remands eXMs to ramose all of We remains and other material firm the aempon
caemmer. bNpme minimal dust and residue will likely W left behind, The cremd«y udl separate Inudemal and foreign means frgn
sunshade
u remains antltIb Inddanlananticeg denalwill be dspder W asreC bylaw i global
remaipswillhem ndlno
rylves Argument
Imbsmallp'lews and placed alsol 4&Bsde]«ntargrdum. Lmpbd remain yenanly vn pulrerleed urr011 no
dn0b hapmen[IB ncopnlpbbp NulablflpW.
OPENING OF THE COWAIN�
The crematory mes only omrl Me container bolding nw uscreneW human remain In Ilmibtl circumstances, shards as to confim the
kerNry NNede ptlormawurear no mdend isentlmN xTerfor Mlflwschastptlal tneutalca flee N
Ilunann will am anelboed Ina COdtlnerwie aledWeuldbbbncryma0bnvudracpts Me nialal11lpake4W
will monde form of
bamavM Idoasu sere a shows
and it accepts foenmains. TTeopenng INe
WnMimr ortae imMbr orremovel0l r&nains vnA d Mlducle]Wore a wimp%antl unit Ce bane in pnvery, wilco tllgnit/and rpcep,
IDENTIFICATION
Named ssM: J yW. NMI Mdibl SidW. MadM
Last Known Addne. 354 Main SY, Coll NY TZOS
Plan of CesO; 351 Mein Sl., Charge NY 1382flM
Sea: SM DF Pge: 87 OOB: 0&1TI1OM! OeleINOmM. (SH8,202S Esnmaa.NWdght tp
°sacsption c!cxkN¢nbinx In xTlcadorraeunitis quesd.
INPdmadnellmMeYmanuf Curer) Mgplers prtmra Ntu!aM LaNbarE Cremenx Cdrdimr
PERSON
(PYmNi In 00l ddiapaslPm, MMI ONE area,Mloidra
I grJtM1b a'ethe dfagnded agent dthe denal sharpened In a Nll10r wrNen inhumed eieabd Wrsuent b Paul
Health taw Aedpr 9301.
OR-a l
IhVehead nor Me damedd the hens ereml awarom Pediflowing Pucks Xmer Lax Sdnon<N11 «e
vnn Wndinirg tliretlions for Me dieWaodn of his"fix remains and Ilwe stage penpMa)M1avirre i d o u puCma XeaM Lew
ShM.rI OMOt aM aavetae rgMbaNM1onzecremadon of the rxraln9dMe Mreased. MylOurnletloundereM1lpbfM demaN by
follopers
JBllrry W. Hall
WS-IM d-f 1Rw.all Page 103
Autmoriution for Cremation and Disposition
(InaeRfipngepef 0ebw)
Numpm 3 Diameter. 3urvwingwlk
Gers g TM1 d^ m®ig inn Npursuamto Puwm Hegg Secga Qolt3I
adomsas. The survNn domestic paMer.
3. n urriwnmg cl eigmeen read or age or Ober
5. As"wel wMi t
5. Alaxlutl ce¢igmendeen, olage or altler,
yaCgointeEl Yew n
T. My ceROn(s) eigM1gBn yaars Olage OrolM entitkE to eM1are idled sable add who 'Ware Gaest in relNonsNp loge EYAaeeE',
r. A duly appointed fiduaary of Me eskM.
9. A cross Mend m made wed M1y exttWm a wished ant 0m WraueM to Pudic Health law Bectim 4b?0I 1.
10, A chief NCal officer 0l a county 0r a public¢dmnistralor appointed Wrsuem to Me Surtpbod,s could Per Kure AR
10up Me,Offer Personnw CON acting an behalf aMe maraud and a s,has mail a written sMl W Malawi do Pi Health
Us(tM ���r%^LL^ THREE d Me ldlaxmg)
�` vN NVa her"affirm flat the Wdy Of Me d S$e does not COMam a Oat@ry pantry pal p-mar qll, mdmtli Implant
Or radiwclive Marine and Met any cum materials were Rmpvee prior to Me eX¢Cumin of tivs Autlpriaetlan Fare Fallon b remove
gw�s�I/blmsp rto cmnstlon may mutt In M1arm to pe mmmWm and cnmtory Mmnmi.
�+ NAb affirm meting acm haveM "I do ROOM 1. O¢namore
r¢gardir Me removal M any personal pro Or oMx Ming of value wrch any pnem ugnMg MI V Wry family memMr of the
4 swdw sbpmserve. Pinewm Crematorium
n nolmcerlaible fm q¢RmOval ofpersonal ilema hdnlMCMrairwr orfmm lie Fme�nsUMadmse6 P na111erm Mtings
coom nsr OrMh Me nmens will OadYtroyad bril Crprla4an prop d manMMrMawd~Cml n
N IIVh IrereOy auMONe Pinevmv Cremelcnum
ypeds" ro
to cm aW the normalns Ofgab[aysetl.
FINAL q$POBRpN
The person aNhdmmj b remirx Ma enter r ns 6Me do M1un the rem Is
Name Root 1. D mml
Addi T Sharman Arxnua CgIrM, NV 12822 per. ISiB)6568R&5
The Dammed remeNa of dOCeaeY all W 68p Was MI
Retuned to qla wik
If W any moon Mece m rrgrp1 a00W does not W9 poses&M W then a(e0 remains,
Pinevm Cremamum isnM wglva WeaeuionM
me remaimto Mnamon Formal Hmm, IncmmmMd,
mail in person or Oyr iatemd . m�xawrruw
Jaffrey W. Hal
DO&l� f(Rav, W15) Run wO Page2 W3
AutttorizaHon for Cremation anal Disposition
flmpffi Ma farow,nea
INJe unaerabM ME if me remains are not aaima went t$o days of cremation,
Pirlevlea,Enamel
an ineMerehle mwner, .owr Sent e®donna. r win
may die W.e of Hn romans in
GeO`NE acre kNownod
crap Murnbpe uaed pgqa��mlWrwkrHgcrynal yralreim nee Ceen Plm3aep M1cn �crn1Xe Furerel Hone, lno,
and a epcnded as fwoen'.�asl u. /,� ♦-r ,f M S[
IMb understand Mal If Me um le ba&1 b hold ag m5m crenated ramatn ,W addsW nd read anal lnm may be UW An delivery.
OR-
_Mum4nwy&�. NW unMrWnE p®aHroumu WrrilasM aoNCrv.Yse Pmvlded
Pied mCRmammum
wave n writ ham Me cremated remama in
a ISO templery oon caner ter di&arcry.
This AUMwtratlen Farm cap prandM by RWa11. pnamore wes executed in
Detainee Funeral Hone. It
Sherman Avenue,Coned, NY 1= we1tlXieyM
and Is agreed Me ell dial as wdness to IS executen. O
Ile heve ramwed a Completed COPY Of MIS AuMorlaaten Farm.
the
al Whine Me
to these Curast Ydand RcomO completeness wNePlnammuUan CanMMed In NM AUMwfaadm FOrm andMIS
auNorta aWon Form, alYeas)
Signed Met tal dtld MW ,p0
Toni L. Hall
]SG Main St.Entail RY 1= %%%g ���•���MMMnn� Li�LCiI
Renee
aYnXE83: ^�
RCEer11. 0anamcre
pmMa+wn+u r.wu my 4a'm
10MO
Johnithr W HMI
WS-1898I. 08,151 Petal