Baker,Heather M. Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: BAWEL RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: Y IIL ITO III 4o n
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
II p6L5FN Btn$KO
NAME: kfhOlil BLICIF10 CABER 13
TYPE OF CONTAINER: + 4 biI b (
j bn7 A,,A(( 11*;(4 ^
PLACE OF DEATH: 315 BPnAl1M (L(G( EDWIPD 1mg
1
ESTIMATED WEIGHT OF REMAINS & CONTAINER IIS IAr
PLACED IN HOLD: nL
PLACED IN REFRIGERATION: ILDT H
DATE OF CREMATION: L-J�I'ZOrV
TIMESTARTED: la* {{{{ TIMECOMPL�QEp�TED: /a
PLACED IN RETORT: BOG MOVED: //Z-- - /ZA
RETORT R IN WHICH REMAINS WERE CREMATED: 5:.11rf eok
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE THE CREMATION LOG SHALL BE RETUNED IN THE PERMANENT FILE OF THE CREMATORY.
Authorization for Cremation and Disposition Nwa ap"a,talsor
Dwon ea newew
oiYCmniex Rea, W Wmh1sn1AMnue
Airily NY 2231
518)4]afi228
ilru AUMafatlon Fvm mmb completed and+(W°11Nfof b tlWvsY of rwrWes W nvnatlon.
Deter_ 611o11d Number_ 739
Crematory Name: Pill Clematory
Address, Quaker Road, disharmony New Yak 12500
Phan: (518AAL•471r
CREMATION IS AN IRREVMR i1 E AND FINAL PROCESS.
Cremation is wnieU out by placing the remains of the deceased and one container holding Me remains had a
cremation chamber where they are subjected to intense heat and flame.The had and flame will incinerate and
consume everything except bone and metal,which are all that will be left after cremation.
Following cremation, the Pomeroy will take rmso mue eRmts to remove an of Per remains and other maternal horn
the cremation chamber, but some minimal dust and residue will likely be 10 behind. The crematory will separate
Incidental and foreign material from the remains and the incidental and foreign material will be disposed M as
required by law_ The cremated remains vall be mechanically pulverized Into small paces and placed into a
designated container or urn. Cmmaled hemaine generally are pulverizd until no single fragment Is reeogntrabla
as skeletal tissue.
NIN CON R
The crematory may only open the container holding the uncramated human remains in limited dralmadences, such
as to confirm the Identity of the deceased or to ensure that no material is antlosod whion migm injure amploy°°e a
damage crematmry property, If human m Sim are delivered in a container which is not suitable far estimation
such as a ceremonial or rental cal tear car Mory will require Mat the remains be moved into a suitable
container before it accepts the remains. The opening of a container or the transfer or removal of remains win be
conducted before a witness and win be time in pragett. with dignity and respect.
IDENTIFICATION OF DECEASED
Name of Deceased: Haebnr M. Sekar Martial Status: Dismissed
last Krwwn Atltlress: Fat Hudson Nm/M k M, 319 Sroad ry Fart EQ , Newyork
Place of Death.
Seal oM mF DOS: 1221933 D°bof Death: /y—a-
Ag°:g(L G�If�3� eaamMadweigm:
Desorption glcaskeVcoMeirla in which remains will be delivered
Carmllaled CaMboaN Boxwah WYwdotl SlertnMk MadN 638800
PERSON IN CONTROL OF DISPOSITION
(Pesar(s)nwnbol dtlla'pmition. keflf ONEofine foXowing)
1 arm We we the desgnaed agent of the decea6ad designated In a will or wiipen instrument execmad
w2ubrt In Pudic Health Law section 4201.
OR-
Jpy_ WW move no knowledge Net the deceased °a°Med a Yemen Irwhumem pmeuam to Public MMM I-eW
section 4M1 or asell containing diractions for the disposition of his or her remains and (Continued nadessel
esteem me, min xme baum Peal Nor
a mare Meparsan(s) haWr pdorkyuwtar Public HaaMLawsection ,1201 and have thenght to authorize
wema0on of Me remains of Me deceased. MyfOur miationship to the received is as follows:
(bead M1wn me lot know)
Number. 3_Oescnption: DauoM1kr
A person desgnatetl in writing Ministrant Pudic H"M Law section 4201 (3);
z The surviving spouse;
2a.The survivin doMe
3. Any aurWWrg auik eig=yea of the or
ZR 9Va fl.
S A sunMng sibling eghti en years of age or olds
e. A lawfully appointed guardian',
7. Any Persons)eighteen years of age or older entitled to share in Me seats and "a Ware suavest in
relationship k the deceased;
S. A duly appointed fiduciary of Me asiaR;
9.A close friend or relative who has exec mil a written statement pursuant to Public Heats Law§4201(7);
10. A chlef Metal officer of a coumy or public administrator aPPgntetl pursuant to the Sumgae's Court
Procedure Act
10a. Any other person who is acting on behalf of the decessed and who has executed a written statement
pursuant On Public Heats Law§4201Q).
(ln&IALL THREE oftot Idowinp
lit,AT IM/e henew affirm Mat the body Of the deceased does not contain a battery, battery pack, power call,
ridioactive implant or redioactive device and Nat any such materials were removed poor to the execution of she
AuMwvetion Form. Failure to romwa Mere Xem pdorro cmmatlon rosy mull In harm to Me crematory and
crematory personnel.
AAA Wye hereby affirm Met instructions have been given k nwmwwenwml_3len Baker #10139 regarding
the removal of any personal property or other Ming of value which any person signing below or any family member aMe
deceased wishesk preserve rwwwrwwn Pine View Crematory is riot responsible for
removal of Personal items from Me continues or from Me remains of Me deceased Personal Items Its in the container or
with Me amalns will be dashayed by the crania on process and cannot be refriwed after cremation.
l% 1l Me hereby apparent lwn vaneyl Pne riser Cremetory focremata Me
remins of the deuasetl.
RNALOISPOSfrION
The person authorze r to receive the cremated remains of Me deceased from Me crematory Is:
Name'. Baker Funeral Home Performed
Address, I I 1.2hrivere Stineed. Quescrusburv. Navy York 12XW Phgrre: f51817614303 _
This cremated remains of deceased vnu be disposed of as knows:
Rehm to family to be decided
If for any mson the person named above does not take possession of the prompted Tennant,
rw+•uo'r•...f Pine View Cematory is alMoriud to giro possession of Me remalnsk
pvnwwkord Baker Funeral Hom by delivery in person w by registered mail.
Heather M. Baker
oosr9blJlsrv.pinw amwwpwaewa A 2Ma
-h y, a/ lMe understand Mat if Me remams are not claimed satin 120 days of cremation,
amrwvwml P' U C t may dispose of Me remains in an irrebievade manner,
mrch as by swtlering.
9HEMATION LONTA NERIURN
(I�O dms once")
An um to W used as a convener for die cremated remains has bean purchase l from
Sake-Funeral Home and a described as Wines:
tee uMaslars Mat title um is too small ro hos MaerNre Oemevd remeine, an additional dgs container may be uaed
for deWery.
-OR-
LAn um has not yet been purthaseo. lMe urMw#and tat if no um Is purchased or oterwise preened
N.+rymmy P'neY Cremalmv wgI Place Me cremated remains in a rmb harrporary
conlairlorfor delivery. nn
This Autorirater Form was pressed by mwa mwevwre)_ snr f]�
area exewler N rmreimna,i.w..I Baker Fwnral Horne
Mwy�+*eeaaneel 1l tafaredeS O bu N York 12800 and is signed by Me fiereral director
as witness to its exeotion.
IWe have receiver a correlated! copy of this AuMoreation Form.
The persons) IdaMMed below Ware the paranoia) in control of d'npoahic n, who by aigning this Authorization
Fame, Mileage)W the accuracy and completeness of Me information contained in tie Autorlration Form anti
audhorixya)the foregoing.
Signed thY LS day of j�, 20L
*rWaRlaerinn yyw,w
]J LaewR,m T. Trw ANary Mw �9
M✓%aRYstlYm ��
AMW
rnpvnFallM,, synb
sower
WITNESS:
wn.aww.rmadrewen.,. saw•
Funeral Home Reg.ID01130
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ne 18wrrl law.Ornel er.ewpICINISH+ ry.amP