Washburn, Clarenda E. Pine View Cemetery & Crematorium
Quaker Road
Queensburyl NY 12804
(518) 745-4477 or (518) 745-4478
FUNERAL HOME; _ -__ n�`:._—_.____.__..__.. RETURN TIME:
DATE 8 TIME REMAINS ARRIVED AT CREMATORY: _ 04120-1 ,M
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMA41NN3:-
NAME: �C((�✓' _._CASE N
TYPE OF CONTAINER:
1N1l - Aya.._. dad_—�.(-__ 4-4nwr
PLACE OF OEATM: , �e:/ _+ ,• '������
_� YL
ESTIMATED WEIGHT OF REMAINS 6 CONTAINER_-_
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION: 3�2j1b
TIME STARTED:
COMPLETED: II
PLACED IN RETORT: __IV < -__MOVED: ___ ,..`LDq_ i�_ )ryIX
RETORT A IN WHICH REMAINS WERE CREMATED: i�t/NT+•—�1��
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 NO--
URN
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG KKALL BE RETAINE
D IN THE PERMANENT FILE OF THE CREMATORY.
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Authorization for Cremation and Disposition
Thus AU dz"tl FORM in unt be completed and signed they to Oallvery of ems ins for consulon.
raw May 23, 2020 Number 61
Cremalay Name: RMwex Charwoman
Address; 210uaker Road, OuemYwry. NY 12 Pae: noapiSHTI
CREMATION IS AN IRREVEREIME AM FMAL PAVCEBa.
Queen son le denim am by pacing the markets of Me decimal aM tlw[ember twl3rp Thad remaiM Into a cemanon Weber where
1 ey are aubjeciN W,tense Mal and Ume. The but flarMMII Winooski consumer everything decided bone add ml
which are all May will b Italy aMr counselor.
Formal comemon, Me crematory will take residuals aflea W remove all of he rename and diner normal horn MY cremader
chamber, but same minimal dust and residue will likely my left behind Me normal veil uparkM Inudental and farrom bell Man
the remains and Me Incidental and foreegn materal air mendicant INas named crew, The GflMhN ndie will bemedianic IIY
pirvnaed Me small paean and platedImO a dangled!Real a arm C WR im ge lr am puNwdwd umll no
eingIs lrsgment is material as Wlmal lMw.
OPENING OF THE CONTAINER
The memamry may only open Me mribiner baking the um=mebd human Randall hilockl uumsarcxn, Such as to confirm Ne
,denbthuman eamnssamm d IMed In a container which is of sullable for�trxnadon uchyaas""o Nl or nth casket.the
my "
al will ruie Net Nw T IM ha "a Moved Into a sub "RH ls container Were It accepts NMIM. The Openingala
mmm re
quirk,
Muni ranOval of remains air be conducted IMom a wnnp9 and veil he domain pi who dignity and respe[i.
IDENTIFICATION DF DECEASED
Name of cemase0: Clarel E. VdYM1bun Mendel Sawa. VAdvxed
Lost Known Morass: 2172 CIA Ww LrcaM NY 120W
Plebe of Deal: 2172 Cell SL. l9d liars.Now York ftb41
Sex'. ONEF Age. 85 DOR. 03Vb1925 DMoetOaagu: OSR312@0 EsdmMd WagM: // /h
Deschchim 0 brommWMeMer In which ¢rams will be radial
(typdmmnallm eVmsnuh mar( MaMusws Purom va l and CemWaN Crystal Common
p RSM IN CONTROL CFOSPOST ON
(Perse(a)in cmUolold'eMsitm, fadel ONEdHd Mlowingl
Im att Msignmm K2 Ol edeceksHdesWn inawillums nInstM nt"me kp=uaMWPublic
Herat ldw SapbT Q01.
-0R
C� " We have ro bvMMge that me damaged exahadd a when mmNmeM Weuant W Pudic Health Lew Section 0201 or
will wham erg lirMims for Me 1pecimen M his a her mundane and lines we the peRe(m Mary immety under Rude HMM Law
Sadden 4201 and have Ne light W aNMRize serval atl4 RaMms 0Me dAYMed. Helmer elandonshlp W Nor dmeaved Its as
Waves:
Gable E. Wxhtum
DOF1898J(Rev. Gals) Pegg 1 of 3
Authorization for Cremation and Disposition
nnranad ma rabeawt
Number. 0 Dependable bn: Survival Daughter
1. A Ohm desbmted in marl appeared b Publk"I has 5echean 0]01(3):
3. TM suviMng spouse;
y. The sun'Mng someone harder;
3. Any central shad eighteen years of a¢or man
a. Aaul parent.
S. Asurdvino aiblNg en Need years ofap or deal
B. Ala fully appointed guardian;
L Any Asonheeighteen years W age or bMtt mi to eraRln the cache and who ipare closed In relationship to the discussed.
0. A duty ordained fidudary of fire estate)
B. A dose mend or elatie who has executed a actual dmandl ph chant to Public Hearn Lear Sat90n 4201(7)
10. Apush fieral ends,of a col or a puts wernnueber spherical pursuant b they,Senegal a Coun Prembers Ad
i ga. Any 0lhar Assam end a aUng On aehM of to decpaned and Ww has amended a final 5tamment pursuant W Public Heart
Law Sell thee(]).
du/t/y ALL Thai of"Nkadmi
�. 5 I=eherebyaPormthat Neb yott dereasddoesndwntainabbery, mtlaywk, powerealf radioactivea laM,
IX ra4oaded devire and that any such real mile removed should M¢exNalion W his demrhatlon Farm Failure m mnove
Name Xnm prlorm cnmatlon dry mutt In harm to the credal and cmmMry personnel.
IAYe arm mad unicameral have dome piron to RM&t I Dem ndd
regeNing nw removal of any mpeaul promrty,or order thing of value When any Orson ageim lemx or any deal member of the
dxeaeed Wehae W reserve_ Pinswex Geodetical
Cri
Ii Mre¢pansible brehs removal ol(grepnel iWms hdn the rantalnerorhom lib remyna IXme dNaBeOd Pr nal Nam iMlnme
maWnerorMm me"dicta t baM""by the cmnMon pmmm and pal be MMVM of W cnmaNm.
M hereby audrmW Pimvisw Cm Mum
m cm am ma mnalm o me McemM.
FNALDIBPO811bN
The Name addel to receiu9 tM common reman¢IXme demand fmd V9 vmntlby 4:
Name: Rcdn I ( memory,
Add. T Sherman Awnue. Cwiral NY 12W2 pbey. (510)050.taB5
The mounted opeol W@WON all he pages M AS for
Burial In Can"Rural Cemetery
It V any handed thin perwn named YWa deed rM dose�m of the UNmtM remain¢,
Plmmemn mm iselMzef Wgwe of
cameraman
me and.he Damaged Formal Name Ind, of,dWvelf
in ql¢M IX W establishment real
trammel
(AveMa E. Audi
D0814db1(Red. W15) nMno� Paral
Authorization for Cremation and Disposition
mime MyaMrry
yz__5_ INJe unEentane met itm s rtmaina are no[aeimMwMin 1Raborne W oemdm,
charges Ctimamdum
an matbveae manner, such as by acanedrs. m.�.> n may d'reppm arthe remdnem
(CREMATION CONTAINFJM RN
r�oNEdma ravawmy
mum to are usi as a CO mfIXtleaemleNr mMs been ma sw Maus Omamwe Fannie)Horn Inc
and is Eeewi a¢MbwS
Age undetebrq mat R Me um If IW& l b read the embus vema RmMM, an eWitlMal Nd CMNifer may b NaE(IX tlsfry
HdFF
(An um IB M W WrtliaeM. INJs uMmebb MIS if he un is pwWaaed wdMwlse prodded
PlneNex Cremeromm
vdI plain tea=mat remains In
rwsuarwN
e rigid lempoary mMeiirer M d4MrY.
TMa AUM zN on FarmvreapoaMeddy Rcdrl l' Oalmtae was Mounted
menernamer Funxal Home, law. m.,...'o...m.w,..i
Sherman Avenue. fmnM. NY t2eur
and is sigma by Vq Nneral diencr as w ess to b research
Ii dove rtteiued a completed MASS of hie AU mzm on Form.
The warrants)IdendNd below Were Me penoMa)in wnlml of dlsposNan.xTo W signing this AU udzffin Form.albsNa)
W the accuracy and compMawae oldeny homestretch cmtllrW M Mls AuMmwaMs;Form and aumolzat eforegaing.
Signed MIS Uld day of Ncy .as
CGnmla SMneoad
2212 CeII SL, leYn liueme, NY 12Me
mrna
r¢awn,.!mna.e pus
Robert I. Mane mM
rpnnwrraW 1�
iretgs
Mai srMeh
clawMa E. ywasbbum
a.—.ass
OOSie�fRW.W15) Pqe 3 W 3