Sparta, Susan Severance Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 Or (518) 745-4476
FUNERAL HOME: Mj
-----.----. _ _._ RETURN TIME:
DATE fl TIME REMAINS ARRIVED AT CREMATORY
Pam
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING 1 REMAINS:
--.._.._ noacn
NAME:
— _ _ CASE N 6D p
TYPE OF CONTAINER /
PLACE OF DEATH: .
ESTIMATEO WEIGHT OF REMAINS 6 CONTAINER
PLACED IN HOLD; _
PLACED IN REFRIGERATION:
DATE OF CREMATION. --
TIME STARTED: )I;
TIME COMPLETED:
PLACED IN RETORT: ___ .__—,)IAnM —MOVED; _
RETORT P IN WHICH REMAINS WERE CREMATED:
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 <gEMATOgY.
KEW YORK DIVISIOn Of Deesrrnenmsmte
SONY F a DIVISIOXOf CEMFTERIE6
OPPORTUNITY. Cemeteries Pau
slowly NY uZmaWt
♦Wsruwm eed4ami
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Authorization for Cremation and Disposition
Thus Aum au Form must be composed and signed enter to Ilellvery or remalrq Far mmatlen.
Date: 0snv2m0 Number: 682
Omani Name:Pine Yaw Ch maber
Addreed:Quaker Mod,Oueensbury. MY 128N Pliede:5147451
CREB ON ISM IRR ERSIBLE MD FINK PROCESS.
Cremation is marked out by gedrg Me amain of the decaased and me consilM hoding the Numbers Into a oremMpn gleaNr'MIM
that M subµCred to imenw heat and Mama. The hound attempt will Imimmte and consume everything except bane and msbl,
which am all that will be IeR after cmmtion.
Follavbng cremation. Me crematory all take reasonable opens brands all of the remains east other magenal Men We cremation
chamber, but sane minimal dust and resbue MII likely W MY haland. The summary will eepare@ examine she foreign mended hdn
theremainsantl Meincitlenslandhmi9nmekh wllbedisWo 01Wrequiredbylaw. ilea cremated remalre utll be mxhanlppy
WNarVed Into small paces and clause into a designated connector um. Cmm remains BanemllyM puMNd until no
single he9ment Is mcognlubs as skelesl Uawe.
OPENING OFTHE COMNNER
The summary may only open Me member holding the unuemmad human remains In hundred circumstances, such as bmminan Me
ItlenNy of the deceased w b ensure drel me nahenal is enclosed Mirk might injure employees an damage the crematory property N
human remains am dalMred In a conshwr which s net embble ter cremMldn such an ceremomal or rental casket,the
tharnaluary will require that the remain be mnvsd into a suhtabb consumer baron It smack the emans. The opening ola
container arms transfer m removal of remnbs WWII accentuated bmwa a mound and will ber stone in privacy, MM dgniry and msw .
IDENTIFICATION OF DECE ED
Name m Deduced:Suaen SBWranw Spate Mantel Status:
User renown Address 2W Main SL Hudson Fells, NY 12839
piece n Death 258 Mein St,Hudson Fells. NY 4839
Sex'. OM IMF AMu63 DOB:211&1957 DM Of DwM:5120M Estimated Weight. 110
DwMmion of maskNwldamer at Mich mm sell be deivered.
Flaelyp (C k #A Cll C((vrl yu le c_I �1� tv.�n en-yrtm�ti�
PERSON IN CONTROL OFOSPOSrt ON
(Pwaon(efmronwl or wapawmn, &MONEofinedwOWLny
I erNWe ere Me resistance agent n Be deremed reslgnatio in a will or xi Men Inebumant executed pursubmi Public
Heats Uw Signal4MI.
-Its
3 D' Noe have no knowledge Met the depressed executed a wren lreWmen purment to Public Health Law Sadden 4201 or
Wil¢nmrsng dlRNone fir the dhsIssatem of his or bar remora and thee am Me 1¢rsonts)having priority under Public HmMh law
$ on4201erhm'e ManghttoautMue Mmetionofth remains OlmadWeSed. My urmW*nshlpMtireM029dleae
Mims:
Susan Severance Sparta
inswurmensix
DOS-18984plev.041i Pabi
Authorization for Cremation and Disposition
Onsaa/mm th Pv b.kwf
Number. 3 Dean Mew BurvNlrq Bch
Z Ap mnw r desgw wring end d in ng comm b Pi hoddho Law Samoan4201(31:
28. Tim surom A domestic peMer',
]. Any aurvNing child egnle6n yeamma9e or older,
4. Asu lvmg parent
5. A Marcos amend egnleen Miss of age or older.
6. A IatMl"PwlntM gamble
T. MY Mmn(a)elgMsen years of age or older emnktl to mare In Me estate eM and Ware soon In relationship blue amended:
a. A duly apWntea fiducal led estate',
S. A cents Mend or rebore area has command a written statements pomodest b Public Heels Law Season 4201(7),
to. A Chief fund l oxmar of a county«a pu bon admbido-ator,appeal pursuant to Me Sanction a Coutl Pmmdum Ad;
108. Arty door parson who4 acting on behalf M Me dece66ea a nd who has executed a whom akmrrcnt WrsrmM b Public Heats
Law Micron 4201t71.
muse ALL THREE of Me Meaning'ZYT� �r Me he"all Mal the body of rlre deceased Mee not contain a battery, be6ery door, pos urcel,radlo9Nw impkM,
dimension,ch lw and Marry such reaches were removed pMrb the ecomfor of this Aufhw agm Foot Falluntore "
i 0 Ibms Poor b mamaaon may mutt in harm to Me ammabry and mmelory"mnr .
,: D, more aMm meressuNons have been given to Tom G.KIMmr goo•
sgamin00e wall of any common pmpeM1y or other Minn A welm which any peen sgning below or any Sandy member of Me
aewawd wiLas b preserve. Pare VIM Bmnalory
19 net reaTprYble M Me mammal A Miami items from Me coal or
from Me rarrams of the deteesed Personal Xama It in iM1e
a finer or Mat Me normal ad 11 be destroyed by 1M Cremaaon process and Cannel W rNmencd down shoulder.
Me hereby euMorlr Pine Views,Crematory away
m rnmm a9er remains n Me a.doa..e.
L WnrH1AL1
Yore Mmby auMer4e the named funeral director to moi for convert to and cremation by an alwmaw
edmaws, It deemed necessary In Me optmon MMe funeral Mercer, and to amend this form provide de the co name and
ema of such mesas commonly.
FINAL D sPGaR oN
The pares auMphDa to move Me cremawtl mmair of Me Mceased from Me Consumer,is'.
Nam:M.S.all Funeral Home
Mal ss: 123 Main 3t.Agyte, NY 12809 Pedal: 510-7238A216
ham Nam mobs W tlmmaeed win be ahpnedmediated
red WNI, MenirweNe Cem'mrv.WMam NY
If for any seam Me mean named ebowe aces nm bed we sion of Me nemaba hums ,
Ping View Crerrbry
a euNmimtl bgFra mewubn of
the remains to M.B. fiber Fumml Home Er,deMery
In men an by regional me. a....+tu.yMm sew 8dorte
dem, Mil
Ws-1 Page 2 of
Authorization for Cremation and Disposition
\lfM�Cdre aw»my
/� T_ho• MN¢uMwsMM tlultltl¢remsFa ere roi¢kimee xYMnlID eapaaxretion,
P'nn New CYerretory
anlmVrevable names,suMpby scgry¢Iing, n.swn�*un
may mapaee Of Me remains in
CREM
( CNE Or the Iwii
An um to M used as a MlHiner mr Me IX¢malee rem6irm saw deem puRaa Mean
sued is eessnbed as milown:
Me understand that If am 'c too mail to 1 me mft oenuMe remains, an aeemow ri anlaFer I Ire uepead MaYmy .
oa-
J--or tMourua W tnno"ispurchasOeV W iseprmdW
PIMView CmnaD,ry
Wit plane Ole memaMd remains in
a rieie mmpomy,carbalnar N Midwest,
This Auftdn gm Forms wse piotby Taal G.Inmm was examined at
M.B. Kilmer Funeral Home 5...✓amrwma
pn.ww..raw
123 Main SC Angle, NY 1YPlA
and IS Signed by Me brand dimmer as indent to be seestim. agyW
I nave R[erved a completed copy of has AUNwlxedon Foal,
The per Identified below ratan Me pereords)in mnbol of elapcWlan,"a by signing Me Authorhatlon Farm, arbatls)
To the acWraey and complepness of I IMamulion conned In IF AuMotlaat Farm and auMommi Me forpoln9.
Signed this 22nd day M May p20
Justin pwkee
rr SC935mW m3 Spate
Po,i0,AryNe. NY 14S09
Arwee
WRXFSB:
TOM G, glmer
1 Ida
Rwuowa M�+vanwar`iN Tnn
110]9
Susan Bmremna Spam
Iurrwamrw
DOS-18I III"I Pape 3 a