Stanko, Kathleen A. Pine View Cemetery & Crematorium
Quaker Road
Queensburyl My 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: LOT E6%yy - — _. RETURN TIME:
GATE & TIME REMAINS ARRIVED AT CREMATORY: I/�r _ S-a3 -AO; (j
NAME OF FUNERAL DIRECTOR OR REGRISTCREO RESIDENT DELIVERING REMAINS-
CASE ----- _
TYPE OF CONTAINER:
PLACE OF OEATX: - L/.tY1da J1nln�c fR��>�L�1!
ESTIMATED WEIGHT OF REMAINS & CONTAINER_1 � -,-
PLACED IN HOLD:
PLACED IN REFRIGERATION: AT _ - ---
DATE OF CREMATION: S'Iu i,a
TIME STARTED:
COMPLETED: _ 1
PLACED IN RETORT:
RETORT p IN WHICH REMAINS WERE CREMATED:
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN AB HOURS
FROM TIME OF ACCEPTED DELI VERY:
NOTE TxE CREMATION LOG SHALL BE RETA
INED IN THE PEgM<xENi FILE OF THE [glMSTOgT.
Newyork Ne
td4YN
aPBAPTOWANX:RK Division of D^ I NOF CmMETEMES
Cemeteries 9v _^;Waver"
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TueFnwalme:6bl.Meva
twowdosinvigar
Authorization for Cremation and Disposition
This Adumbration Form must be eompleba and egned phorad delivery or Promise for emmetlan.
Oman: Number
Cm MName: RAdY pwnataY
Address'. zt Goal Raced Oueen¢euryi NY 12800 Phome (518) I45«77
CREMATON IS AN IRRWEM& E AND FINAL PWCnS.
Control coal am 4 pletlrgthe hmein M me Mimi and Me ancestor noNirg they mmeim into a mora4rl die rMiele
they amsuEletl bananas neat and Fame. They tans Mmawlll lnclrerab and consulate ew lrlp except ame and MMl,
which am all Nat will the Ma affair cinnamon.
chuFdbwlg bid So an, Meal road
and
will a Re l fare eXOft a ind mall of Nam Sol a and other melenal ham the madm I
the remaibNnd th minimal tlumemdreldu0vulllwil selethseMnd nuemaby volt sepemte lnti mmundbreignm aniad hdn
0e remains incidental plb gnmaknalvAl [ed inedorum Ciretlnybw. Tteu 11 mmaim willse u"enio
singlemily
fragment
irlbadesigrrel0d WMHinOe or um. Cnmabd nmalrls pPMnlly en puMrlxed urNl no
¢Inal.lmpmem is maoamssble aa.AElr,f ands.
OPENING OF THE CONTAINER
The crematory may only open Me mntlineP holding the uncmmebd human remains in limited circumstances, such As in confirm Me
carry Nthe drici ale ensure metal royal ame10¢M which might injureemployee¢or damage me uemekryproPorty If
human remains an det"i Ina model which Is nth suNeDb for Cremation such as ammi or renhl cal Na
Mabry will requlm Nat W remslM he moved Mesa suitable corlYlner Were Ratmp6 Me remalns. TM q&iing We
container orthe thermal removal of mmaim As Mmnducted before avnbed,She veil de done in pnvacy,am,dgnTy and Isapect
OEHi FCATM OF D ECF ED
Name of Lbceaz Kathleen A. StAme Mandel Sbbe. MarrM
Wi Nnoan Addles: 17 Jams Read, Lot 3. S8 "a SPnngs, NY Ideal
Plemaf CeaN. 17 Jams Road. LN 3, th retse6 Springs. HY10e66
Our O M E l r Age 64 goes. 10/06/1955 Dane W OeMh' OMW2020 Eatmaded vme m.[�
tt Don of®skWw rowan wall remains all be delivered.
Cardboard Box veMlo iden Base
PERSON ING MTROL OF DISPOSITION
(Fbmat(al lnconbNddapoYEP'r, my¢oNEofmafnpdmrrN
I YnNh am May dasignatod aernt 0 ma useful d gmW in a All a unman InWment ww purauam b Public
Heats law eactvr 4d01.
.OR-
m11'S• IAVe have no kmaYdme mat me demaaed executed a mien instrument pursuant to Public Heats Law Setaon Adel or
Ad containing direrdom he d¢co¢Ntn of his or bar remains and ✓nee am Ma powerful having prionN under Pudic brain Law
factor Q01 and have me rg Wauthaire uemitien Nthe remainem the dewaand. MylOurml"onshlpbNeft a$" Mn
rots
Kathleen A. Stanko
DOS-1a (Rev.0aQ0) Parallel
Authorization for Cremation and Disposition
pnndnwn me for b✓Owl
Nu r. 2 Oeo om: Micnenl Sinn (Spouse)
1. A moron Mermaid in wring pumuml b Public Herrin Any&Man 421;
L The surviving spouse:
Ma. May surviving domestic paMen
p. Any sul chip abandon ram of or or boom
4. Asurvlvlrq damn[
S. AwMving sibling egbem years M spa a Whom
8. A IaMUlly address guamlenl
T. Any panel eigbeen years of age ar Kier mti to same In Me arms and who ✓ere cb M in madhomil b ther aBrl:
a. A cub eppolnret Paul of sea Ktele;
5. A close Mena or revel who has are W a written sAmmem pursuant an Public Health M as sawn alolp},
to. A chief boom orciWr M a mu my or a public adminia r appointed pumuml to the Formal a court FmWam AM
tat. Any toner prom,who is among on be barrel May crossed and who nae amearw a wrlryen$�er Pumwm to Public Health
Law 5ec5on azotOL
bromma ALL THREE mesa AW kAw,g)
M,Px li herammy atom Met be May of ne semi Ones col contain a MMry batlery pad. p FCip. Mloadw"ant.
of radioactive Mealy and Has am sucn Mann a Were removed prior W the execution Of this Auham slow Form. Failure b moova
Mesa Home odor lc cremabon may mutt In harm to xe er =n and tM &Wy pemomel.
fVi, i', Sr IMb aMrm Me11ns1ru lions nave UOBn glrenb Fall GG r. Han
rygeNing tM renewal of any pemmG proPoM or ORerlMrq INvalrereiacry Gerson aignlrg Oelow warty bmiymvnlW MNe
demawd wiffiO b presase Pe chow Cmnalay
a colt nave Mine removal of pomonalialms ham Xn amairer or ham theremains of to dewssed. Poraonal XeresIaa In ham
mmonpr or MN Me remalM wal b Mohamed by Me cmnaXm process and mnnat be MO defer crematlon.
M.P S. NYa Frreby euNorize Pane Vex Cnmafry
revsaw,
bMmvb Na nmtln of tlw daeesvad.
(trod OPTIONAL)
Mew Hereby moderate Me named mmml director b provide for delivery to and anomalies by an alb
mabn.X Maned national In de opinion Or Me brutal bracmr,am to amend tab m No Promise,M e verses(name and
Mlof such albmmla cremabry.
FINAL oaFslTlox
m pe
rson school bm®ave dB aamamd remamu anw M®aaed MOM down anuamryla'.
Nine: Comgsabnate Funeral Care
Adders do3 All A'R.. Sam" sMr4, My 12W phne (518)S by
Tina Mremains bed aM ton the die aIS kllwn:
Hamm TO Farmer
Xbr aM rwwm the omen nsm Wine MOSS Me i pcuaeM of Mom mnYm,
nMvewcmmalar is auuOMad of oaa PSSvesxald
the,remeimto rcwmrwu cargo removal Cue. If by MMlwry
N persm or by wp dmay pees~ MYNNn A. SbmO
ppS188HIftem. Cul nMn Possi
Authorization for Cremation and Disposition
(MNeMaterial
m,es, WA unmml Nat N be remains are nWa¢imal whim uo Manor mwnisso,,
Pine Vlex Closer may Mlapms of Ns remains In
an matiembk manner wcb as Ey srstlennF Rhs,wumeery
CREMATIONCONTAIHEMM
(h-R ONE OfNs,Wrowmm
M um b Ee uwtl are a mMam br Me annest l remrne bu men puMa from
also 4 MwaiGM as Isdi
Miss understand Nat if be um is too was M Mp Ns,MNa uemabM remains,an aA' NTeI RFN¢nb'SIR man Es uM MMNYmry.
tlOR�-
11ru5• M lm b not yaf purNawM. WJa moderated NR M no um m pu"T or arew6¢pruar
Plre View Cr MMe will dam der cremand remaire In
a net rsmWrary conlamer for Maul m�.✓arwun
Thq AutlwrbeMon FOM x Pmm by Rolland G. Hi was executd of
Canpassmldt Funeral Cam, mcod
di IfirA Std SrW13
sorm
ends mail M be marmaal diremr as sodas to to it Rental
��
INJm bass,rem'Md a mmplolN Wpy of MIS Autlro "on ForalThe .
g Me
ror
e emcCmmoa anaandard d wm pSlNa sof Me Nformatlon COntlneM In NMileAutlrort MFoarmn freedom)
aM ubor ISI tee MMV'n.
of N
refined Me 22W dryW May ed
Mideast SbIJd
tT James Ped W3, Se S^r. Irga, W team
rwunvrvw aware,
WITNESS:
ROIIaN G. Hon �
d 11838
Rel A. Stenko
OOS-iSdbf(Raw.(MOM Pi 3of3