Citera, Mary A Pine View Cemetery g Quaker Roa Crematorium
it
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: _ �pw
RETURN TIME:GATE & TIME REMAINS ARRIVED AT CREMATORY
NAME OF FUNERAL DIRECTOR OR REGR13T
EREO RESIDENT DELIVERING
PPe REMAINS;
aZC �.u�l _ .
NAME
_
TYPE OF CONTAINER: _—CASE #Y'
PLACE OF DEATH; -310 /� -�F•�'--
ESTIMATED WEIGHT OF REMAINS B ---CONT4INER_
PLACED IN HOLD:
PLACED IN REFRIGERATION -
...—_
DATE OF CREMATION. _ -TIME STARTED:
— --____TIME COMPLETED: _ Z! __
PLACED IN RETORT: �—
MOVED: _RETORT q IN WHICH REMAINS WERE CREMATED; ,_ - �
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN Ag HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION -- _ _
LOG SHALL BE RETAINED IN THE cEpMAHfryi FILE OF THE CREMATOgY__
Do"Annu tcateM
NEaW FORK Division of DMEIONIOF NEMETERIES
Cemeteries •^I^ 3Quo:
am
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arrovalwhyrov
Authorhuatlon for Cremation and Disposition
The auMwlaefwn Farm most be complained and agree Poor to eel Ifthery,of leMIno Am wmmMlon.
Doi SlfeizD III L8s
crematory Name.Pine max cram um
More— Quake,Road Owen bun. NY 12804 prove:
CREMAnON IS All IRREVERSIBLE AND AT PROCESS.
Crematpn is mitred out by plating rite mmelns of the dandruff and the container rddln9 the remains Ina a vematbn Nem[e,µtge
they are arblected to intense heat and llama. The held and Dame will lminenM and wnsumsave ing except bona aM wa 1,
mariM are Al met will Ce left after cremation.
FolloaLg cremation, Me cmmmMry hall Two reavonaWe eXadeb urnI all of Me remain¢and other mamoel from Me vematlon
chamber, but some minimal dust and rescue wild Ilxely be left beJlmd. meammet Whewamnmdden0lanffore4gnmatortmnom
IM remains and me Inudental and Mnlgn materlm will be degrees ore¢required by,few. The uemated remains Mll ce Thunderstorm
mNMred inb mall pubes and pladv Ina a 0hignmd wmanor Or um. Cnm mnalns genndly en pulverized until no
NngN fragment Is ncomissbb 0,skelWl Unt
OPENING OF THE CONTNNER
The somebody may only con the wnla nor hddlng the uncrema mi human remains In limited amum¢tanwa,such as to wnfirm the
identity of the decebetl orto emum Mat no male^al u endooef whlch might injure employees or damage Me nemmory pmpeny. If
human remains are dNMrall In a conpinxwhlch Is not sultable for confirmation each as ceremonial or casket,the
costo will require that Me remains be demand little a suitable conala w babaw It accepts the remains. The onap of
nsumerry o,the transfer or removal at emains will b r conducted helms a wxndss and will be done In invest.Wm deurry and reaped
IDENTFICATON OF DECEASED
Name of 0ecresed'.Mary ACMre MNdI SdN¢'.wmo
Last Nmwn Ackdows 390 Cash SbeN,Saebga Smng¢, NY IOWA
Piece of Det 390 Chumh Sj Ua aSpring¢, NY 1296
Sex'. OM IMF Al D0S:O212214O Date of Death O51332020 psljptsd ProgrL IA IeB
Dt puce of caste MOer In Mtich remains art l The del lae ,
Meahews Cardboard Cremation Tray, Wood Bottom, Cardboard Top
PERSON IN CONTROL OF DISPM WN
(Pertavii M conrM On dlapa ,, ihowd ONE of corks IdbwLpf
andri are Mr markdown agent of Me tl ARM dedlgnMad In a will or woman Instrument executed punuanl W Public
Healed Law Section 4201.
OR
GIM a haw no knowledge Mat the dwsawd executed a M n lronmenl pursuant N Plead HaelN Low Seuio^<201 or
binirg f is
drauirds fw Me disc¢ ofM¢whernmuns add asks dnda or¢on(u)having prorly under Public HmIM Law
<ID1 and have Me X9MbeuMMv cremdlNn cited remalna of Me demawd. My/Oa nlndomhlP to the dwea¢ed Is as
Mary A. Cites
DOS-1 Mail(Rev.0420) Fags l of
AuthoAzation for Cremation and Disposition
Number r 5°M.wf wbq
Nome De.mpmn: erah.r
1. A person amlgwtea In wmmrp mrmwm to Put Heron Lure Smllm 4201
2. Tlbaumnng spouse:
Mr. The NPRIN domee0o w0nn
S. My surviving cold olenreen yeam of ads or sere,
a. A shoving parent.
3 ANmal among eighteen rears mate or older:
a. Alewlully appointed gw vmd
T. My paleoms)egnban"am W age or deer brload b share ,be eared tea one lWare Gwest In relarmi to be aeceasM
S. A aulysppomba daudltie ea .
9. A dada Geed or werve who has avecured awnNnstatement Comment b Pudic Health Lew Secllm<NIIT).
ID. Achm most ommr of a mueNor a public aamlmmmor appointee comment o are surrogate a Court Procedure Mt
lour My~Mmon vTO do si on behalf of the dNwQw and who has ue Hd a amen gEMmanr b ri b Pobtic Health
Law Sachon 6201�)
Medal ALL THREE of fhe Mbwtrq)
e he"emm Met Ms may of the eaomvae m.e not contain abaltey, mnery emu pmWr Dell. radioactive lmdam.
Jd del and Met any such mmenale wsre remwea plot mlee o.aosin m this Aamwrmbn Form. F.IlumRmmay.
mete Items prior to cmmatinn may reedit in holm to the emmebry gad cmm.W m personnel.
Alm emm Mat instructions have even grom to Mae N.Pansh
hg the owner many wmcwl pre gorother thing of Made amen any"man erasing below or anybm u llr member
a a Wa wehas bpreserva. Ctea vow Chernobyl
Is not responsible far the ramovel of personal dams from the Conner or from ere remains robe aarruraaw personal hems ten In the
aentaln.r or whim the remains will m destroyed by Me cremation press and ethanol a rebtevea after otem Mnao .
Me hereby author Pon aw Cnmatalum
r
to arem.te the reml of m.a.ruras.a.
4DIOSTRUIPWIN
IONAyIMe hereby aumorla.Me mmetl hneral director b g eM dN Ivory b and cremation by e n alternate
a o n deemed necessary Ia Ma opinion of the Nneral dinewo and to amend this term b provi the conM name and
. much aftemab crematory.
The pawn amh zee b receive We venmbd remains of Nor decrosed ham be aemmary Is:
Name. fumi Funeral Home.lnc
Mde 65 Main 9, Hudson Fall NY 1209 phone: 518-0O74203
The gemmed rmim of a9pa ere be dw sW of es bllowe:
Burial at Union Care EeMan Surbl
n fair any mai the ml names above deed rot lake m se of tor aemm mmslns.
%M via,Cramemaum Is suMp Wb91W pWantion of
1M remains IN CoNWn FUlwnl Hans. line ter"am
In pa2cn or 4 reglsbrea hole �n MarfA Clbre
DOS1596f ftl Cat NW203
Authorization for Cremation and Disposition
(Lai gl th Mbwm9)
1/W0 bMG X uMon NNe Mergers are malmM wMln net earned 1 YO coast
a marbn,
Yw Lrememnum may dWµ MtM remems In
aa.ac.,..wn
MMVMW mamor, man as by scanehng.
CREYAMON OONTAINERIIIRN
(illat ON a lMq^^91
Pnumbbeuseda¢acontainer ear tM cremated rowing has amen Nr cod ham Bele¢alle
asoi wl as knows /when PVMer Um
Me understand mat now mm i¢min small to hoed Me onnn crowded nmams,an accasonal kind comamermay no Mind orNllnry.
-Q,Z-
anminmnMyetpmrenmsM. lMeM dmM dmnnrouml¢pur andwmlwn Wvmed
PIrc View Cnmam um well prow me managed remans In
nwvacwd
a wild bmpsary wntainar for di
This AulRodratlan Form was provided by Met K.(eMh Ma executed at
Carlemnicneral Nome, Inc. M1rMm l
fifi Man St.Nud¢ot Fall¢, NY 12838 mnwlu�arN
and Magner by the funeral director as want M exaction..
Me have,roNN a completed wpy,of Me Authorization From.
The psnonp)WeMIM below plan the terrorist In conbol of dispwNlon,who by Signerp MISAWwtlistlon Forms.MdI
to was aceurary and compderese of Me IMarmanon carramed In NN AethorlrNM Fomr and sulhMnp)ma mnpoeno.
Sinned only $fim tlry of May .1p $0
dcM Yankee, X n,✓
a
$N GMytw18 Road.Vera BUN FlOMa SRM9
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VAR
Mar
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Min N. /
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12872 v w 5wsw.e.ew.+r Te
Mary A. Gore
GOS-089&f 1Rn.0MRO) Ismit