Mundell, John kjj
Pine View Cemetery & Crematorium
Quaker Road
Queensburyl NY 12804
T(518) 745-4477 or (518) 745-4476
FUNERAL HOME: Ca� lp RETURN TIME: -n✓s /AX'
DATE 8 TIME REMAINS ARRIVED AT CREMATORY: ljb -
NAME OF FUNERAL DIRECTOR OR REGRISTEREO RESIDENT DELIVERING REMAINS:
mark �P aI #1•
NAME: J Lj M,,,iAgII CASE DY
TYPE OF CONTAINER: I 4/4 ,J 41✓/ 40 AAMIAI
PLACE OF DEATH: M/�Ine 1'JG Pfi,hl �-M' J /.1:.44ke
Bg7C,G. .* U.u�G/ v ��IIlvfI✓✓ 1207B
ESTIMATED WEIGHT OF REMAINS A CONTAINER 7r Aa
PLACED IN HOLD:
PLACED IN REFRIGERATION: -04
DATE OF CREMATION: /9-9 Z
TIME STARTED: IO _ TIME COMPLETED: a*Z
'// ✓PLACED IN RETORT: MOVED: / � 1'
RETORT PIN WHICH REMAINS WERE CREMATED: Pyl 5 p/S_ A 11
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN AS HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SHALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
Authorization for Cremation and Disposition a•. )� 1 1\;p
Nwre.ar,2vY
mrmua x2n
TAq Awlavol Form mw0e cpmPMHardalgosdP W deasseeryWrar2sYls Aarsmmslgn.
Data fl mbi 7/
onemamry Nana: P,U£c9fid P Pthc F✓- fTbP
ndareas,,�/�a n yn N` Plwn.: S/B' 7YS 4Y7 �
CREMATION IS AN RtREVERMI MO F1l PROCESS.
Cremagon to tuned our by placing Me mnmins of Me remainetl and the complaint hulEing the remains Mp a
counsel tramper where May ere subjected to intense had and fame. The Matand Maine will inclnembe and
eoeryrbing except bane and metal, which are all that will be left all cremaarm
Following co mearks, the cremerary will take maaonable efforts to remcve all of Me remains and Other material from
Me as left behiniL The
Mirpnpl and foreign rreprel' ham Me relarwas and
me inciaalnml amend forego melehal Ail ae isry roll sposed refarate
Me
required by law. The carrahttl remains will be mechanira is pulverized into smell pieces and placed Into a
desgneted container or um. Cremated emaina generally are pulverized NOW no sight fragment is
recognizable as skeletal Neaue.
OP OF COMA NER
The crematory trey only open the container holding Me uRdenmle0 human remains in Ilmbed dmunula . such
as to confirm Me identity of the deceased or to ensure Mat no male ial is enclosed which might injure employees or
damage crematory CopeM. N human remains am de ivered In a container which Is net suitable for elematlpn
such as a cammonial or rental casket, Me control will redeem Met the remains be moved Into a suitable
examines,safom N accep6 that remains.The Opening of a container or the transfer or removal of remains will he
conducted thecae a witness and will be done In privacy,wins dignity and respect.
I ENTIFlCATION OF OECEASEO
Name of Decaasal: Dfll'f A1J?_ L Menial Stahm: Q to Olct- O
Ian Krwwn Address: cr+7 //JY IQa Ifi/�/ /o2 darL
Pla®W Deans: Y 70�A1J ( ' h2Q//11 R.Stu: �M OF Age: 6 1 OOa: DebMDesul 1 d EaMrepd`MN91R 7�S
Deacipkdn Mmskagmnblrer N wM'ch�m�Tans well Its elevated:
n I eUkhv`± nzsnt` A/& s
PERSON N CONTIFt0l.OE D EPOSM911
"reni N conbd oximumbi take ONE or me following)
I ant M am the designated agent of the deceased designated in a will orw ften instrument executed
purauerd to Publia Hmeh law section 4201.
�Wy R-
vt' Nina he"no knowledge Met Me deceased executed a wddan instrument PumcaM W PubM Health law
section 4201 or a will containing directions hu Me allocation M her or h"i7, 7 �swepgN
I .,J. 1 I-I n . InFtG
opsasaIF (Few, )NON lm.dm s.alwa
! !hg mnswba)
I� Iis u�gymtentl tha"rftge are rot Gei in l2odaysof enarrEm,
such as by,u Y 4 l'.IeST `W '7 nreydinl>osa of Maremeinam an irretnevabk manner,
such as bysadeng. '
MEMAMIN N
(AllItilt ONE a th rdbwrvlg)
_ M Ian b be INW ma co ttemer for the cremated remains has bean Pumitased mom
and is tlescnihed as follows)
M mewa.m that gtlre Ian re M an®p b held the mere aeeaed remain, an adtlifiorml rgid ccrdwner may lee
used for salivary.
�yy -oR-
�F Mu nd yet ben Punulleaetl. NVe undnatend Ma IF ees mere Wrshsred or mais In a N tovided
pnreyys.op( /�. i.c� (rQrnnA'9t4�/ wIII PlerameCremBwtl remains lnadaN tem�reN
mmeil�er(n dal
finis Aullrol¢agmn Form sa Plmaida
was emend at MnwhwrwN t
rv�ww�..we�N and bagnedM tllsXalvtl Namr
as wimass toIts execution.
INae have received a oompieted depy of this Aulhs dai Form.
The demands)identlfled same Want me isee mnls) in wrmal of disposi who by signing this
Authodvdon Form, magnates)to me assurary and comPletmeas of the Information ooMemad in this
Authorisation Form sect ortmes)mee f/ere-oo_ng. /1
Sgned Mre wy 7 dmf 1 /�a-- -SIG
F Ila a t^ ��if. . toe C tin444
17> p ,
Addled
.,9M a'RMtl N.. seem.
aee�n
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tgR ES � L
I.et.nr eaNevrw
979
an N1
V In at L—
oos.txw Iw..mnw
rrose r.aara
1 sMwa are the psraun(s) having briefly under Public Main taw sectKKi 4201 and have the tight W auMaize
crema4w of Ste remains of the dxnal 111I mlaMew Ip b Me MadeoeJ h an follows: ,
Pnmtawn rna nymro 1
Numbar:_ Oesalpbono
1. A peWn designated In wd8ng Paduniro Pudb Heafth n aacion 4201(3);
2. The surviving spouse;
2a. The surviving domesac pander:
3.My surviving drift eighteen years of age or older.
a. A surviving person
5.A warning sibling eighteen years of age or alder;
8.A lawfully appointed suasion;
T.My parson(s) eighteen years of age or older entitled to share in the estate and who lslare chased In
relationship tot" daceesed;
8. A duty appointed boundary ofthe estate;
9. Aclose Mend or rea9vs who has esecNed a wntFen statement pu2uent to Pudic Heats law §4201(7):
10,A chief fiscal officer of a county or a public administrator ator appoined pursuant ro the Surrogate's Court
Procedure Act
10a. My other person who is acgrg on behalf of Me deceased and who has executed a wslen statement
Pursuant to Public HedM taw§4201(T).
( ALL THREE Nthe/dgang)
Me hereby affirm Nat the body of Me deceased does not contain a battery, battery peck, power cell,
adicactimi implant of adioacdve device and that any such inebriate wee monorail prior to the exeardon of this
Authorization Form. Failure to rempve Cure tbae prior an cromauon may resuN in Trim m and
re MM preannsl.
tWe hereby affirm that instructions M1ave been given to mwvatournwnw l
regaling Me removal of any personal property or oMc min9wpt a wM1icM1 ary� rorRopagnirg fernery
memberdme deceased wiahearopeserva. r�wr�.mi—Yiat l01 Fw1 (iv(4hNM@ru / is not
reasonside for removal of personal bona tram the container or fmrn the rertaina MMe de mead. Paaonal i[erne
I in the cimainer or WM Me remains will be deb"W by Me crana0on prouee and cannot be retrieved
cremation. /�
Me hemby authorize rw•.dr�ro / /�6 �/ fiJ I .QfNniTiCta consonants
remains olme daeea nis.
FINAL DMPOSiT ION - •
Thepersan uMar¢edt,pJ@cerva Me cremated amala of Me deceased tram Me camel is:
Name: Y b€� `h�k> r.:'rf
Andresa; \Z6 O �a g 6 (_s•ut
This crenated rdraka ddecessea will nd disposed of as falww:
nyu.etioTo �rt �� aa
If for any rmwn;I/he person nenr@tl ebwedou col take poves hoof Meedto g drareins,
rw�'rvx) _f rwlLUa£.al l`1Lzn ATd @rtt"�ia auMw¢od to give lweaesaian orMe rem.im to
mwa'mw.m�u ad..`rF by doMryhtpwaenr Wre4staed rnsll.
ntlrJ I_livlosc `
p la as, moot xa.wo®e wagon