Corliss, Nancy Lee Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
I(518) 745-4477 or (518) 745-4476
FUNERALNOMG RIMII' _ RETURN TIM!
OATI STIME REMAINS ARRIVED AT CREMATORY; _�(% - (,-l7-ZOZO
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
ln/ r-4A..I eTLk :s
v NAME: J /IR�✓ .C�l L[��r /rSS CASES 7>`'
oZ
�y J�✓d
TYPE OF CONTAINER' pI1Lw w P♦/m.I"h1 Pe((g4� >lnfe Ass Gski)Gl. PI H2
PLACE OF DEATH:
I IAMB
ESTIMATED WEIGHT OF REMAINS 8 CONTAINER_ ISIJ bh
PLACEDIN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATI
O
N
: G-/'/i Y�2o
TIMESTARTED: �-'rz TIME COMPLETED:
yy
PLACED IN RETORT. _J�g _ MOVED:
RETORT R IN WHICH REMAINS WERE CREMATED: Q?Akf 7I tIG ,z
DETAILED REASON FOR DEWY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG Sxsu BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
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NOsur W VORK Division of DIVI lM CENMMES
Cemeteries AnalDOetppl
Towardel5telwl
,mommen,
Authoriution for Cremation and Disposition
TM1k AMorizstlen Form moat Be CM*Ddand apned prlorto valley afrowl Air aremenan.
J'a
Dow.,June 1T,20M Number :
—
CrYNtpy Name:Pine Yex Clema W ry
Mdmum 21 Oman RoW OuenneWry, NY 12000 mane. 518-746-4477
CRBAIATION IS AN IRREVERSIBLE AND I'll PROCF .
Cremadon is marked ad by plaang Me remains of Me dtte and the wnwiner made Me remains Into a monsoon chamber where
May are eumcwdJ b lumae Leal and flame. The but and flame will lnclneraw and mmuma everything eaupl born cud moral,
which am all Mat will be Ten after cmnagan.
Folio ng WmaWn,Ma cromabry will take reasonable efforts to remove all of the remains and othe r material from Ma cwme4on
dial Mecme minimal Ownerd resdue will likely be left bahird The cremMory MII sepa2N Incdenbl and foreign malnowll ham
the remeinsaM McInNdenbl am foreign material will radical of As required by law. Themmaledremainswilbeme nkally
pulverised ImoamsHpimpendpix Into a mysgwwdmMainermum. CmmaYdremalmgenemllyampul MLdunBlno
single fragment to mmenlnae as mi beam.
OPENING OF THE CONTAINER
The aemably may only own the container holding tom anuema human rem.ma in limited mamatures. each as to wnerm Me
keah01y0ttlptlereuetl normal Mel no ma nah is indeed Audi mightmal employees;or damage the cremebyproy a
human remains are delivered Ina mnNlnerwhlch w not suitable for cremation such as commit or rental cal Me
nmatery WIN require that Me mmalm be moved Into a sultablo mnraMar before It accepts we remalm. The owning do
match or the transfer or remowl d Panama will as WMuRN Werea unless am wil Par domain pm'ary, Who dignity am reapnct
IDENTIFICATION OF OECELSED
Name of DMmaed. Nancy La Cakes all stal Dmm
Left Nncen Pddrew 8Hour asset Hudson FNIs. NY 128W
Place of ouM: FM Hudson Nursing Horne, PIN Bmetlwey,fin EOMN. NT 12020
ANY Din OF Ana:74 DOB. 3/1/1945 DAN of CeaM:OnenD2o Eshma MQK 150
Du oon of mmericabiner In which remains wit be Daniel
Minimum Cremation Casket, Florence Casket Co. Cardboard/Pine
PERSON IN CONTROL OF DISPOSITION
(PMM(91 in Cmel a dgNdi , in1 ONE of Me bUxfngf
I amMk are the items naked agent of Of Manuel uagN In a will or walMnImpumaM Mohamed assume Public
HeeM taw section 4201.
a� jIi have no knowledge Mat tM model emwwd a wrltwn Instrument comfort M Public H M Law aagbn 4201 era
all cm ems;tlaaclms W Pay draauadhon of his or her remains aM may are tM persoMa)homing prioll under Public HWO Law
Sactbh own am have Me mot b whomer assume of form remains of the mmeetl. WMur nlWonship N Me doomed Is as
tWlmaa'
Nancy Lee Corliss
C031888f(Rev. 04,20) Page i of
Authorization for Cremation and Disposition
(mmrtrmm me 6x mrow9
Number 3 De¢aption'. Any eurviv'Ing Mir agbin)een olps woke!
1. APomer oesgna in among pursuanito Public Heats 4w$eW 01(3)I
1. The WNivy epees;
3e. The suNNing armmes panne,
3. My Annoying dalth eNhWn"am of Mewolder
& A surviving parent',
5. A nation;myng aigwn"am M age or older,
6. A lewlully appointed guar0larp
L Any persond)eNhen yearn of sage or older$ngbtl to shore in Me"i am who ixare Gosetl In methanol to hsdeawed;
& A duly reversed smmery of the scow;
6. Atlme friend or harder who Any Moused a wMten state Pursuant W Pool Is Health Levi Section 4101(7)',
10. A MIef bSwl cmwr of a county a eflues Arm real appointed pumWM b the Sunogete s Court Aoradw AM
has, Any other Person who is more on behalf of the defaamd and who has Autmbd awritlen sMl oM Rommonl Is Public Health
Ufa Serum 42DIL)
(Inlml ALL THREE a MB cala nnp)
Aft harry andm Mel Me body W An b d dean rho contain a mail battery geld, manor fall, hsyoxlbe Implant,
or Amend"Mid en and me any such materials were removed poor W Me execution of Mrc AUllr aWn For. FallueWromova
Mass Items ptlorb crowtlM may rMuktn ham by Ms wmatery and crematory pemonml.
pWd iArm s MM instructions have ben gidenW To1] G. KYmer two®
man Mire W remorel of any fa alpr;eM or other WIN of value which any mmon Not ng below or any family memNfof tlb
deresAM wishes W Israel PIM V C2 alory
ttm "i
is nM re¢pomiMe Mtlre removal of pwwnal lMm¢hmm the wnMim or from the remain¢olthe dewaaed. FamnallM sNXln Me
conMlmrorMM Me mail will on Mmneyad by Me cmmatlon prM ms and cannabis roldi afar cremation.
Me hsmby auModca Pine Water Cmmati
he chances Me remains of Me momsed.
Ibi OPTIONAL)
Its hereby auModm the named NmMI dlrmWr to provide for delivery band mmatlm by an albm W
admatoq,If dmmad necessary In Ms opinlon m of Me hMl direction W n and W amend this la provld sMe coma"me and
dmu of such aHemaM orowW y.
FINAL DISIffMN
Tom('.emon "Amend W mnew Me w oW mmmm of Me dewasm from to crmmAy is
Name: M 0. Kilmer Funwl Home
Morass: By For E M, NY 12M pie. 518-707-Wity
Tn.cmmateo coma rdmm¢ad win uv�Fa ba dbpmmo. P3r faakn;
Y u DrN
If M my meson Me parson named wore deny any Any pvmeaim of Me estimated remans,
Pine Will CrvnaWry ganMw'oedtogydnpoueuionw
Ma ranairoW MB. Komar Funaml Home by dell
in motion w by regwWred mall m� N cy Ue Col
DOS-flyri(Rev.Ol u� Pgle 2 of
Authorization for Cremation and Disposition
f�ptma rognMngr
.¢ IMh understand Soldier m lns are not demand were lWayeaO nineteenth,
Rrre Vew Crematory may diepxf OtNe mnum in
an metal mal sued am by afa@nng. ade w
CREMATION COMAINERNRN
(IrvfielONEoftlre Asses g)
M urn N he used as a consumer bb9 CRmoyd narni has Mein purchased M1cm
and IS de9uwad as Mucham.
IMb uthadand Nat IF the um is tm small ad NMtl me entire demands measire, an atldA alrgd ecnbiear may Me used he deanry.
.ore.
_M um se ter yet Promise]. men understand Net N n0 um IS NrN oromhwke prwd0]
Isam Way,Crmlay vnY aYeMNO uemebd nmeine'm
Mwwa�TUR
a n0M h a{aruy container far delemry.
They AUOros ft form wri OmNdM by TCW G.Knew mmawms�e was aunNMrt
M.B. Kilmer Furenl Hmme
B3 ItiaNKy. FM Edward, NY 12333 su�ry �wr
and is signed MY tlw Nrierel dlramor as waterways to l@wancom0n µcar
INJs hew ROiaid a demands mpy 01 Nis AUNo/ltarlon Form.
The annually ftd Mtlow Imam Me"mends)In control d Mated oq what My a Inning Nb numerousness Form,tlbMla)
to NM accunry and wmplNmu of McMrtormallon cn ned in Nla AU odzaNan Fmm and auModzyq Me sumBoing.
Signed Nle rind di Jum .m 20 .
Elemental ward
IM17 Indent 0W late.OauNwn. NC 28036 —
Maas
WITNESS:
Todd G. Kilmer
Mwr o.m.rvfwr
11879
sma
er Nemy Law Cordes
Seems rro
DOSlC (Reu.NUO) Pe]e 3 of