Gagne, Delia R G�7
Pine View Cemetery g Crematorium
Quaker Road
Queensbury, NY 12804
y/(518) 745-4477 or (518) 745-4476
FUNERAL HOME: ArD�—.. _____._ RETURN TIME:
DATE 8 TIME REM4INS ARRIVED AT CREMATORY: 00
Alt-
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERI�E•MMAAINS-
-Te�t_71A
NAME: ----
",ka LP,/!('I. .__—. _.—CASE p 477
TYPE OF CONTAINER-FfDcRAz J-
'' �r�'—fry
��1' — MTiw
1 aN61.Er�wId.MD9�[p¢a,..2
PLACE OF DEATH:
- — —__� -S-cl,>aoa_[�k�.,,✓
ESTIMATED WEIGHT OF REMAINS 8 CONTAINER_,_(�,S
��•
PLACED IN HOLD: '--'---
PIACED IN REFRIGERATION: --
_._
DATE OF CREMATION: ---'
--.. 9!uj,A _
TIME STARTED: ZPA...
'v -.—._-TIME COMPLETED; _ iDIN PLACED IN RETORT:
RETORT A IN WHICH REMAINS WERE CREMATED:DET
MI REASON FOR DELAY IF REMAINS WERE CREMg
FROM
TIME
TED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SHALL BE RETAINED IN THE PERMANENT FILE OF THE cgEMgTORT.
_fN� ElNroaa Division of DlvaaN�o^ce�EErEwEE
�ST YOM1 UNITY.
L Cemeteries Army, W122a,_ppm
.wawme:I5m,oh n
Authorization for Cremation and Disposition
9ge AUNwMNpr Fmm must be completed and signed Poor W delivery Of
rea ry for cmmaEpn.
Date; 18.;sfn NumOW. 20tyl 9 7-1
Cmmnl Name PINE NEW CREMATORIUM
Address QtIAKER ROUND OWENSBURY,NY 1281)1 P)xq. 516745,4I77
CREMATION IS AN IRREVERSIBLE AND FWAL PROCESS.
Cremation is canoed M Eyplatilg May re'nans oft h sell and May mnYner Mkirg Me remains into a uemaUdn cMmEa share
Ymy are Woletled 0intense llsit ate flame. The Mal and fklre will IMMerab and Comuma eWrythMS ea ONmro AM 1.
which are ad WII he left after crx on.
Fderef Clemaxon.v e a&TeMy will lake reasonable eflons in remove all Ofthe remains and other mwenal franc me cremation
chambx. Me Wine moral dust and racidue will likely her left beMnd. The oemwory AN separate examines AM fr ign material Rpn
me remains and Ilw inamMl and Meign Hall call M disg6N OF as r uired W law, The eremamd remains wil he informyroally
pulverised Into and peace and placedina adssignaled Wntioner a un, Cm rT mHitach y am Wlwartad date no
Ad near fragment Is recopninh as Wtelal unua.
OPENING OF THE COWMNER
The vemalory may only open Ow¢nbiner lidding the un=MO dhuman rechains In limited arOlmLenes. such As to anfirm the
idendtycl Nede SsWaWnnsure Mnnomaledal isendosedw ,i might lnlumemplOyeesordamage Mev a[MWWeNY if
human remains are MilF Ina Conramerwhmh Is mtauluhle for usua n such as mramomal wnrMl wkM,the
maary Are craftsmanship mnaiM W moved Irma smtame consumer Wom Iuccphfne nmalm. The cpenmg of a
whamerortne transfer or removal otrermys;roll l andmcetl betorea wdressard call W done In lxiwq,with dignhy and respell.
IDENTIFICATION OF MCEASED
Name of Dommew DELNR.G NE Medial Staters: DNORCED
LaG Kncvm Address I TINKER WAY SCHROON TAKE,NY 12PO
Plaxot DealK 11 TINKER WAY SCHRMN UJ(E NY IW70
ga. 0As El age 60 Does 06/25/1959 NOW OeeM:DSeV1120 FMimaed ht. 125
Detimpdon of rsakaVanlaim in when remand fall Ce del'naed.
FLORENCE CASKET COMPANY/CREMATION CONTAINER/CARBOARD/FIBERBOARD
PERSON IN CONTROL OF DSPANITION
(Persor in Motors Mdlywsdlw,addejf ONE of May IMWMagI
amNJe are Na deYgnamd aynl of me deuced dens aW in a AM a farm instrument evecrded pursuant W Pi
HWm I%a sermon 4201
/OR
y� All have an kmMadge tat the deSeseb eferNed aAhead instrument pool to Public Health LAW Search ONlt Of e
MII roya g directions for Me disposion of tub a her renans and low we the afforms) raring Moray under Pubic radio law
Serlion 4201 far have ere risen to aNMdae Remotion of the mutual 0 Me dettasad W10ur mWd ip by Man dnowmad Ism
foiw
DELTA R. GAGNE
DOS 1 feel Nev. OM20) Pgje f OF
QMth"U"On for Cremation and Disposition
(Oxen Many me 4&Oelavl
Nomw S pesoipOsn: CHRDA ON
t. A parson tlngretetl in ruing par¢oare b Pude Heats isv Session 4201(3)',
1 TM involving Somali
L. TWBUmi iy Ewn GNmter,
} "serowling tliild aghloan Years Of age or dEx:
A ASoalli parent;
S. A aboard Doling elgMem years of age or mean
6. A lost appointed Invasion;
r, AM peraon(s)eighteen years W age or olner a bodro¢nse in Rio Made ON asp iLare Losses in marl 8Nip b tM deWase
S. A duty DoointM fiduaary of tree eaten:
9. AGwe send or relative was has overused a when Aatwnent purwerm 10 M0l is HtlM favi Season e201(7),
10. A Oaf heard ofiur of a cwrtty or a public administrator appointed pursuant to the Surfgate'a Court ProCebm Act:
bell. "Oder person who is acting an benall Of tire bossism and inn,has esINabd a MNen statement torment b Pubilc In
any Slmm<3011TI.
,GALL 1MREE d MB ltllcwnepl
/ 1`1 /� IMh nmebv amrm mAtoe badv otNe dewaced dors rW WMan a oeXery. Wdcy paU, pine cell. ra4asdw impvn,
on mdioarevetlmm and tlaal any so,materialaxne removed,at try,Dominion 0%a AUNonhelbn Form. FWura b revive
/Nxeibme prlor io Conan n my muR In harm b Me Intermediary and cremabry gas mi.
Wr'm alarm Nat lnffiwlion;have ban given io JpMES P.MCUERMOTT
F.ir✓wmw..
regarding Me removal of any p mined property mdMr tnm9 of wade wlvT"Parson s5nlre header m any famhy member d ire
PMEMEMCREMATORIUM
deceased wiasees to pewrve. �, save,
is not responsible he the removal M CersaW years been be container or hen area reman¢dNa tlaeasad Paraorul lbermlaflln Rw
nYever Or wain Me im Mil balaltq'ad WMe,Inmmailon Praaea and pnnW bar mbiewad agar cmmabon.
Y MreRy aW, PINEMENCREMATORIUM ¢wra L-l— pctemaiethe remelna altlnde[waed.
balig OPNONAL)
IM'e hereby aumarue tlK moved Nneral Moment to Provide for Gantry b and MMdM;n by an abemao-
/ If deemed rwcnaary In Me opinion of me heneral Bereation and m aboard MID arms b pmvida me coRNt nameand
addreu of each aRamam cmn .
FINAL 01 SITIM
The pare0n Wxviaad to re2lwm Ne edemand remsns d Me Misbehaved thin ma umn m:
Name: AAMES P. M➢ERMI OR EMPLOYEE
Adtlreu.
9 PINE ST.CHE6TERTOKRNY 12817 Pledw: 5ID-1 all
TM vemeMh remain¢dMneeW wall be dished Masbtlwz:
Ifbl BnYruDMdb pmWn namatltlWn doNMlYe Weaara'rwe ofRm rsemeW rainwear.
PINEVIEWCREMATORIUM IsaIDeaiaedtogire red
Me remains RARTONJADERMOTT FUNERAL HOMi by wd
drew w
In Pont Or M rgy¢dred mil. OEW RGAGNE va�nora�
Pay2ul3
CO5.184Rbf(Rea. CMM)
Authorization for Cremation and Disposition
(n M1Mtlre h4Mn91
WJa uMenranOlner Iltlie remair0 me rcl tivme0 xM'vi 130 Faye olcmnaUon.
PI EVIEW CREMATORUM «,ay dle[Ova Of Me remalnaM
an lneeleveda memer. sum ae by aolreny. uavwm
CPE lT CONTMWMURN
(1Miel ME of Me hasp. wags
M um to M used as a OsnMlrcr br the cremabO ramaim Me bwn pu liwM MM
and is Oeapibad AS INIONS
WJaundW@M Nat n the um IS NO,Smell to Wd the enureuma rembne, an aMNorW n9M C w mry IN Meant he deassoY
flF-
/,�/ Pn Ie WrUawd. VMaltlgaed JBW HMYnuptlWealp oNarntae povMM
VIEW CREMATORIUM
M .NI pLxe NeaeineW mne'w N
a rgld langorary mnNlner M dOlvery. uawn
ThISAWprIZWGFOnnveapav�dby 3AMES P.MCDERMOTT a�rrvxw yae aXBWad al
BARTONM➢ERMOIT FUNERAL HOME INC.
9 PINE ST, CHFSTERT ,NY 12817 v uww
and IS III by the Nne l(MMIX by Ow to M SOMMOOn���
IMa have rectivad a Menpleted mpy of ads AWNe/ ft Fpm.
The pareonan)IdyNMd Wlw MASS Ne pxemla)In cpN01 a dlepaalllOn Wro W slpays,INS Authorization Font an s)
to the abounay andro pla nm a Ne lnbrmatlon mmil In NM AOMwlzsl on ForanIIaVNo bn9Wng.
819redtlNa ZONE day of IMY at BE
CIVARLESTERNEY y
P.0, BOX U DIAMOND POINT,NY lZol
3,15 BLUE PIECE ROAD NORTH NUDBON. NY 12855
JAMES P. MCOERMOTT
12330 +rwdm.mx.m
woman DEWR.GAGNE
prss�a
DOS-I&I 1Ray.04W Pye3ol3