Najera, Michael A. Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (510) 745-4476
FUNERAL HOME:SI iJ�I $ //1✓c✓ /L.IL S- pRETURN TIME:
DATE S TIME REMAINS ARRIVED AT CREMATORY / — (P'/7- 49zo
NAME OF FUNERAL DIRECTOR OR REGRISTEREO RESIDENT DELIVERING REMAINS:
SAf24// �l�. ' �n -f
NAME: MCA,G / ,N,l/J� erR ,y I CASE # /IS y
TYPE OF CONTAINER: /W nne�{/ � 'I4'(/' '4AM/ .JIM'NPJl I� N.J 0.�6ke
PLACE,OF DEATH: 6)P .-2 -9t/5 dvw� 1. l - Ax> AA !' -FM/4. 6'jJ� 5 /%
i✓ Y /�R�/ I
ESTIMATED WEIGHT OF REMAINS S CONTAINER ?7 / )SS �S�Z I.Gr
PLACED IN HOLD:
PLACED IN REFRIGERATION: 9-:34--
DATE OF CREMATION: (/)ISi tI TIME STARTED: 7 wSHNy TIME COMPLETED: wqoM1
/
PLACED IN RETORT: Al . MOVED:
RETORT # IN WHICH REMAINS WERE CREMATED: kRl- �NSARIY
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN " HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SMALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
1 Depamnmlmesun
NEWYORK Dm Ce CEME E$
Division of Owco"w"PI,,..
"'" Cemeteries 99 ,NY122 :
Al
Mill lmR44462N
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Authorization for Cremation and Disposition
ThN AUMOilmaan Fern must the campMlee eM Signs prbrb�Jbllwry of mmalne for onnuted.
Who. W/1112020 Number 7 1�
Cmnamry Name:Pine VIewG(rem$tory
Address Ouster Road, GueensbulY NY 12804 ewe-. (518)74&4478
CRE nON 1E AN IRREVERSIBLE AND n1UL PROCESS.
Cmnation Is wmee Out by placna has whom N Me MceewJ vJ the wn is heMYq the remains into a mme Membm Mwe
deyare subjected to human heat and name. The hall m4 dome Mil InCMB aMc Sri evarylMrp sawpl born am.m 1,
M 10 am all Mai win as laid area cremation.
Following eremman.Me nremmusry with hike machine emits to renoe all of Me remema and other ma nal mom Me automation
member food,coma minimal dust and residue will likely m led chi al The v«remry..0 awards Maemlal and enough maternal ani
Me remema and Me mceemal and cargo material owl be disposed of as revuirid Dy all me namayd remain win be interminably
parenzM into annual pews and placedinto a d"ianB ccmeinerw um. Crm retrainsgerwralyerepulveda u"lrim
single M1pmxd is racognlvbla as skeletal tluw.
OPENING OF THE CONTAINER
The crematory may wly own the wnyinr hwhing Me uncre human remains in limited circumstances. such ae W Confirm Me
Identify of Me tlewaaed or Wensure Mm M memMl H entlowd "Mr,might injure employees or connotation oremmcry pmMmt H
human remain are demanded Ina wnlainer"job Is not suitable foraremation such as ceremonial Or neat mke4 BM
rxnmerywlll reyulre MN the remains be moved into a sulWla c Winerb m N swpN tM remains. TMbpeningaio
mminercrtheuansrerorm welcfremains MuWwndu lrefaeawitnessandmilW4aInpimry, WMdgri wdmp
OEM FICATNH!W DECEASED
Name of Decouni Michael A Neiere Namal same: Never Married
lam Known AMrew,14 a Standidges lblbw Way. Gueensbul NY 12804
pare of ream.Glens Falls I1osp8el, 100 Park Street, Glens Fells, NY 12801
sex: ®N OF Age a rl1B: =811993 ceaawM: 081I0 20 EUmaMVNgld:�(_Ly
pssc Oon of kWwMiwr in eMm Amain"W
Buffalo Casket G D Y-Alt consainer- ( „) aa
PERSON X CONTROL OF O6POBRION 7
Ipa2mra1m(wahor a N oon, m QYE an 1M nYbwNp)
I anNNe are the sing d agent Of McMmaned designated M a oil for ended command emcuad pnNam to Pubic
Hooch law Semw 4201.
oR-
l' 1/ inner home no knowledge Mm the eem;mtl emcNM a mMan,nemem pursuant to Punk health use swim.4201 Ora
all who inIng dommon for the Moroccan of his or her remains and Moe are Me towards)will pnonry umber Public Health Law
Secdm 42of and havathe right toauModw cremmM lathe remains athe maremed. Nyrour Mim mhlpWMe WceaeedYr
slaws:
Michael A Najera
xifi-I murdeev. wnf) Page I N 3
Authorization for Cremation and Disposition
(IrunM1 the 'eleeaw)
metal 4 IMeMption: Parent
1. A person designated in wiring oursueMlo PuElc Fair haw Smemn u0101:
a The wriNna ewuse:
3. The OUMrng eomeeig wnrer
a Any¢uivgfor client eighteen rears of age or aGec
I4. Aswer running form
5. Aewfully somewhat
ol age KCWa.
a. My proly ap eighten were
Sin
. Adue8onI¢ eighteen Of the age or older entitled to where in MeeWheM who iLare CkMal In nladoMM1ryWMeoxmwd,
S. Acls grand orPors,wholhaeamo
0. Atic¢e MeM Or far of aMohas smmnt hunslto Public HuNM 3gAonron11]l:
10. "a shesulalocerW a aunty or epu0ffof Me diamond andiwho has crescent 8wu nseY Ccut PmcetluB Acu
10s. Lea dMonpension
420 who is acting on OeNMof Me Eecea¢etl and who ha¢ameNedewrillen ablen[nlWrsuanl to Pudic XmXh
Lea sedWn Xxm01
her
AU ]NREE scan rowmna)
' T IMIe MreOy affairs that the lady of Me eemawtl deas net cancan a Cohen, WXery peek, WwK call.cnoectorimplOM.
w RdgeCW¢deMce arq that any SUCK meteWhwOrO RmouBd plwto Me RKutien of Mb AYMvhatlon Farr. FMIIUMWMMova
MMnenU� ms laterM combat my rxull In Mom W Me crematory and cnmdory wnannal.
- J—IM/e am Or instructions here pen glen W Mark JJDaSimone
normal the removal of arty proonal pro a Other Miry W name wM1rJl any wrwn sgnirq Wishes or WY ferMy mother of Me
de seal wishes W prewrre. Pine Vim Crematory
is not re middle ter the remove) of must Items"in Me wmirw or hun 1W remains N Me command M OwlIblrs Mft intlre
onWmr or with led nmslns will W mMroysd 4 Me cmma p s"it cannot he retrieved a rCnmsdon.
ZD)— MW handy handsome Pine Yew Crematory
In.nnrwrx bamub Msfsnwlm of Ms dacaatl.
(NW OPTIONAL)
Iws hereby auMorhe the named wmral dinosaur M proelw for WINery Us and moral an aMr
mel X deemed machinery In fed oalnb of M nera m s forward diumbor, and to emend INS fame m prol Me"m roams OM
Ndraee Msuch SIWm to mmamry.
FINAL oISPO SMON
T4 wrscn ulhoriad to remlve Me vemated remains of Me casommd Mm Me crematory Is
Name Christina Brewer
Andress: 14 B Moose Hollow Way Oueensbury. NV 12804- Phm: (518)41S5851
The perwhd nmsim of m will W tispuad of W follows'.
ReWrn to family
X W any realm the wrwn named abuse tlus MhMe prosesucn of tln vennbd rim im,
Pine View Crematory bsulNaal W goes wssession0
Menmwiew Singleton Sullivan Potter Funeral Home thy,owner
W pawn a dy regia mau. Michael A Nejela
00318g6f(RN-WIaO) PI2of3
fAuthorim lon for Cremation and Dlsposltion
(in M.mgamnsel
NW unmrMndeut Its remeim are rwl aaimMxMm 1m Urysaaem m,
Pine View Crematory mayd4peaeoPorom min
r�w""p"anievenieval moral even as eyscanennq. i
cRFMAVONL TMNEWRN
tinge ONEW IM Idbwirpf
anumro he used as a wmairerM me oemated Moral has Was panful from Singleton Sullivan Pot[er
and is deMnted a foliowx
Me undm4M Nut if Me an 4Ro so lof hold to eNin aemadd lamWs, an addRonel Had consist my W used for common,
-i
\ .f_/ Mum4rrA yet Wndueed. IM1Ys undan4M tlntHmran la pumlueei waMemiea povtlM
Pine View Crematpy wall platy the themosed Real In
�x�naa,ayl
a rigid tempanry cantalner for call
This Aullsommumn Farm was pmvlell M Poll J. NSlmone was e.ecmed at
samiop"Ww"i
Singleton Sullivan Potter Funeral Home
mam" , mew
AO] Bay Ro id Quemnsbury. NY 128M
m.�m,....a
and is gyred fry Me Nm2l air for am rnh4Y toil exeMMA.
Miss have re¢rvM a computed Way of gas AUMorza Farm.
Tlw"memo)NentllW belox Islam tM parson)In conaol al suggested,wlw W signing MM Automaton Farm,a¢ptlal
u the emunry and computennscl Me Informal comelrec In M4 MMor m Form and autlwYal du lorigh lrp.
signed ub 1/th day June , m 20
Christina Brewer ��i,✓1�-/db, ) �'IOi r+e-r
14 r B Mcdoow. RF�t
1A Mse Hdlgw Way, QueanaWry, NY 12804
means
WrlaEsa:
Mork J. DaSitnorre
I �wnwomeax..e amaaumSol
10919
Michael A Nal
Iraur...ro
D0518981(Rey. that Page 3 N 3