Gorthey, Thomas Clarence Fine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME; M _ - RETURN TIME:
DATE 3 TIME REMAINS ARRIVED AT CREMATORY;
NAME OF FUNERAL DIRECTOR OR gEGgI3TEREO RESIDENT DELIVERING REMAINS.
NAME _ 1L^'L_....3•.hIJL_ _. . ._.
—CASE # CJT
TY EOF CONTAINER:
PLACE OF DEATH:
ESTIMATED WEIGHT OF REMAINS B CONTAINER ,_
PLACED IN HOLD:
PLACED IN REFRIGERATION: —
--
OgTF OF CREMATION: slnl,n- —'
TIME STARTED: _ _ (OyI,,, q
T�.ytE.._.__TIME COMPLETED: _� (D oly M
PLACED IN RETORT: _ _ $lyp--_MOVED:
RETORT # IN WHICH REMAINS WERE CREMATED'. _ p
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED
MORE THAN q8 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SHALL BE RETAINED IN THE PERMANENT FILE OF THE c0.EMATOgY.
ate
/�l nmentaa:
jWl EDir Division of OIOI Detrainment
BTPTEOmF
Cemeteries an
Y 12231hydral
Telephone(SIMantibody
now,all IF may
Authorization for Cremation and Disposition
This Au owe Form must by man plaW and signed Prior eel hider of mmalm far cmmauon.
Dow 05J24i Number: 41
Cv amq Name:Rm Ulex Cmm
Address Quaker Rai Q a naeury, W Phone: 518Y4fil
CRO MN IS AN IRRUER8IBU AND FINAL PROCESS.
Cr abon IS 4r Me by placing the remains OI Me dews and the mmaner trading Me remains Into a Randall thermter xMre
they are subjected Io IMenae heat and flame. The heat nd flame will iml ;"Consume everything Somali bona and rmYl
which an all tort will b Ira aM cmma0on.
Following Paul the Reminder will take reasonable anm60 remove all of lM Penney;and other material from the cremation
chamber, bid emre minimal dust and residua will likely he xfl behind. The Renabry will swarstemcdental and foreign mabeal hwn
the remains and Me intlMntal and breign material will Permanent mas Muime bylaw The cremated remains will be menaniwly
pulvenmtl Ines small pews and placed Into a decgmkd mntmw R um. Cmmabd remains ganomlly om pu"NW until M
single Segment Is wopWble as Senegal tlxue.
OPENING OF THE CONTAINER
The crematory may Only Caen Me container hmding Me unRme human remains In fmi4.N ciwmstances such as Wwnber Me
nermuy Of the dewasM or toenaure that no material liantlmed which might Injure employee or dvnage the deal pleaMt. M
human remains are eerveredin a container which S net suitable Wramn "such as ceremonial orrenm caska5 his
coWn will require that Me remains Ia moves Into a suitable consul ben database dace.Pk Me remains. The ommng Of e
nm.sider or the transfer air removal of remains all had conducted bePre awitness add ran be does in privacy,win deputy and reseed.
IOENIIFICATIOx OF OECE SED
Name Of aWa Thomas CIYBfMGIXNY/ Mental Status'. Manned
Let Hnmm Addl:240 BWadway Far Ed dW12028
Plains of CeM 24)Bre yFM EA , W 128M
sa: Elm 13F SRI ooe:6/13/1932 Data of Ne 41174 o Fmumww gm 14O
Omapdm mceM wtl IPer in Pirelli remains al be Mohamed.
Phermta co'ikad C'o ((txnioowdnf a cadh,o�o�
�,
PERSON IS coNTROL M OlaPo91T1Ox
rPamwrrm ta cannaaa->Pweaady m&,oxEaae roaw;nvl
1 anlmx.m Pe eerenaWe agemorineeewaeea degyaWa en a au drwmmePh Imwmnyle.edlPdW wmaant W Pumx
HaaM taw samoyuDl.
INJe hand no knoaMge that the decoaeed ewc.MAJ awheen assumed pumam W Pubic Hamra Law Sharon 4201 or
nmg silect for the disexclum or his or bar remains add IMs me Me pwMdaN hating PriOnly under Public H MLaw
Selcli 4i0land haw Me right to authorise Remauon bond remaim of Pe des WZurmlauomhlpmMada ed low
folio"
Thomas Clarence Gorthey
DOS S96f(Row 041 Fai 1 N3
Authorization for Cremation and Disposition
llnaM/rwn th NNOekw)
NumbsNumbei Indaerplion'.-Fh.a .SUtvN ,t�n Ccnuse-
1. A pmaun deaddraree in writing comment to Punk Heads Law section 4201d),
0, The royal assay,
L. has guying 0omal Winner;
3. Any starving cmd ayMeen wean M age or oiler,
l Asurvarq parent',
S. A aurvmry sibling eigmeen Mao of age or may
S. A carefully g oirXM gunder,,
L AM Rnders)eighteen wears of age or older annual to snare In the estate and wno ivaer closest In Micheal to the aereased,
0. A duty apanlntel filudaty of the estate
9. A does fneM or ral who has executed a wnlbn sbnement Wunuent In Public Hall Law Section 4 lQ)I
10. AaBIB 0Owr of a wunryor a puck methanol Merrill normal M be Sumgane s Court PrcmJure Act,
led MW other peMtn who b%4ng M behalf of the Muauld am wlm has executed a written st ment pureadrat b Public Health
Law Section O21117t.
M//ALL MREE dame Mlora r
W.s belay$Man Np1 the beat of the de sec does not mMem a battery deal pan,, power ml,redodes implied
or Comunre brace and that any soon matenabwers remored preerto Na exe.'ution Cable AUMdrbadm Form. Failure Wn "D
Mi Items Pdorle cnmalion may muNnn lemma me cnmebry and cmmabry "monnel.
pIMg aMrm man InauuCidn9 harm been gi to Toyota G. aimar
specify this remwel of any oat al pcgM or o✓ier tNrp M Klw whcch any Mmon Wayne bebx an My Under member of the
dmessm wanes to pre the. Pine View thermal
is not reapdneiak for Me removal of deemed llama from Me aankcmr�bom the remains of"deamsed. Personal Items left in Me
co��nyytlm//��norwMMa ramalmwill be abandoned!4 Me cremation panem and cannabis Mall after cremation.
M hmby aMcamm Pine VIM cnmamry rcnmoa
l wcmnab that man ns cal Mcwel.
(hated OPTIONAL)
If hereby authorize the named mnenl ecmcbr to pmvla for aslmry to and cremation by an awmm
admaory, If deemed necessary In Me opin on MMe NmminW Ma l dc ,and to arm and form to promde me Coma rums and
dress of such alternate cremabry.
FINAL DISPWITION
The Mason areadmed W males the aemabl umelru of Me dew (hdm Me OemMq Is
Names; Al Kilmer FurcnNkme
Malawi. B3 Broadway Fol EEO M. NY 128M q, pnona. 516Te]-@B5
IT( W nk of l(l=, W 'rpm tlrr+fl
It bar My Warren the Muswl named fambM din ra t4o paesmevm of theawnebd mm M,
Plnev ChaMwy rea Ito that mseosldnm
le..ma•a.+
Me remains W M B. KXmm Funxtl None pylepyy
In Terson or by""h mail Lomas Chrem GodKy
DO&18m-f Kiev. OM20) '� Ppe 2 of
Authorintion for Cremation and Disposition
rin�me rawowmm
IMp anamia.a that if the remWa.m War deemed wmin 1aldays omremabon
Pi re ebry
se,.f n may aiywaal Me ranairo in
an imaievabla mamler soon a by adsorbed m
SBEMAT GN LOWA NEMRN
f�M I wme rosaurob)
An um to be used as a"Winer for The alYnaba r im Me Wind Nrtlmaad M1un
and Is deacMea "release:
i uMeB d Marione um Is1m amyl W had M9F u Wramim� an a]d al real mnhnw may be Mae MdAreary.
An an is net He pumneseb. IMY wa embnd Met if no un is puMw «olMmhs prooded
Pi Crematory
ao Y will Ali He cremated remains In
a Mid lamperary,"Miinor W WIW ry
This rlutlroraati Form was pmndad by TUX G, mY wasS"Stal at
M B. GImer Fumml Home .0 rxry
83 Bm wry Fort Edward,NY 12M n��aaw
and Is agreed by Me Nmml dii mwtlmn to it exemMon�Mm
I ham rerelved a ramdetol ropy IN ntu AuM zrt Form
The mmon(s)Identified
VOM
to Mee accurreccy and camp bnl l Of tlro Informa0on cm inM N bM1 Autllwbatlon Formcar,Who try sig in a s id8)
and W auNONMB 1ore9e
Signed San asar 10�20
l71R vAa
Qa FcJe✓>,cJ , L
�.iimai Wisdom
r,e,.P m,. am.-
W EBB:
Todd plmer
11879 t,naom.arx.m Pwrvazm
TYnma Glenna GeMay
O0S1094!meu. (i WIWI