Jabot, Arthur D Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745.4476
FUNERAL HOME: k'EP3 RETURN TIME:
DATES TIME REMAINS ARRIVED AT CREMATORY: _._. w,170 /NaAnAn
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
C ss OD 018149.
NAME: AHIf ly6lY CASE 736
TYPE OF CONTAINER: 11IM (IS I1 GNIbF.,d IA(Ny-
PLACE OF DEATH: C6.F Ml YYFOIFt I II
ESTIMATED WEIGHT OF REMAINS S CONTAINER nr UC
PLACED IN HOLD: 30e0 AM
PLACED IN REFRIGERATION: ^
DATE OF CREMATION: FIILI70
TIME STARTED: I' IsPh TIME COMPLETED: A
PLACED IN RETORT: LnPN MOVED: ITSr11I Zed\rI
RETORT # IN WHICH REMAINS WERE CREMATED: i7eK4 fWLX
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 98 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SHALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
r New York Sure
���^111 Department of state
07CY OW Division of DIVISION Albany.NY xxll�l
OC,lira ERIEs
aT4TEOF
oPPORNNITY. Cemeteries
tcher, (511114c4num
Authorization for Cremation and Disposition
This AUMo SVa Firm mustbe completed and elgm0 ptlorto dellwry a remains rworamatlon.
ode.
("ll 146 Number:
CmnalaryName. PIneY Crematorium
Redrew: Ouaker Road Queensibury. NY 1280a FMm'. (518)7451
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation is cenW old by pi ng the Me remains 0purchasedand that¢nleiner heading
the reins into B crem bonemail6
y are su landed to Intense heat and flame.The went and flame will InalneM andconsume everything except
which are all that will be Ida after cremation.
Followed;co meXW, the rrematory will take reasonable eflmh to remom all of Me remains and other material from the Cremation
ahamder. but Arms minimal dust and remove will Ilkdy Ce left behind The uemabry wall separate incidental and fo»ign malarial from
the remains and Me Incidental and resign malarial all be disposed of as reguical by Navy The aemaled me ins tell fly mxheniully
pulverized Into mall pieces a he placed into B designated discover or urn.C»mated remaim gerw»Ily a» Wlvwlzed uMl no
single fragment is recognlaabie as skeiedl dNm.
OPENING OF THE CONTAINERThe confirmuch as to
dendBy M the deceaseE or award Met o open the container holding
ll Ala endaxd which might inure ¢mpioy e Inhambane human remains in limited
a or damage HesIX MOICry PropBMN
human remains are delivered In a CWbtnto whim is not suitable for emm"w such as ce»monml or rental Casket.the
»mNgail reyuirs, x Me remalm W moved IrM aIdiluted containerbafo»It accept the»mains.The opening of
contains or the Vammr or removal M forams will M conducted Mbm a atmw and all be done In phvay,w dignity and reaped.
IDENTIFICATION OF OECEABEO
Namedf0ewewd: Arthur D. JaWf Madul Statue: teamed
Last KnownAddress: 18 Earst Strined, ads 74, Hartford! NY 1281
Plarrim Dean: Glens Falls Hospital, 1 OOPark S Gems Falls NY ($�i
Sea:0 M 0 F Age'. 69 DOE: 02 Vm9i Dauot OeaM: DStnnn20 Esti dwelght
Dwoapdgn afceNreYm"ner'n which remains an be delivered.
(WROARD Ia stJX� tT[Sr
PERSON IN COWao FOISPOSMON
(Pwardi mmnice o &d ffmn,_al ONE 0 the Mbarr9)
terminate Meeeagne d agent create decBBsed compared in a all crwaimninsWmeMYN Wpursuantn Pubic
HeeM Lax Section Q01.
-OR
pD_�XJJ
INJe have no knowledge Mat Me deceased e# "a vniNm Instrument purswnt to Public Has
Law SMIOM201 ore
Il Co Making durr iom for tM dlspoaW W his or herremains and law am the person al haWq priOer under Public HeeM taw
Section 4201 and have tax fight In punched cremedon W Me remains of Me deceased.Mi miatlonedi to Me deceased Is as
follows
Rrnur o. Jabot
Mue NOw m
DOS-1898 f(Rev. Mi Poge 1 of 3
Authorization for Cremation and Disposition
Omani me ussemw)
Number'.L Description:
1. APerson designated in wXSr{pursuant to PUNIO Heath law Sec4m 4WI(3);
Z. The surviving edown:
b. The surviving domi partner;
3. Any Flowers child eighteen years Of age w older.
4. A surviving parent,
5. A surrving sibling eighteen Ml of 890"older.
9. Al awfully appoirded ishu :
T. Any personp)eighteen years of age or older entried to ahere in Me eslete and who boare deseal In relaonWp W the dem .
Si A duly appdnted gdutlery of the ntelal
9. A dead friend or rNBOre who hasexenmed a written statement Pursuant to PUNK Health Law Setlion 42019)
10, A&iet flnal ofiwr Of a CouMy or a PUNK administrator eppoi Fred pumOenl to the Surrogates Chad Procedure that
not Any other Potion who is acting on behalf M the deceased and who hasevemted a wrlNen stalemem pu needed to Public Health
New Section 4201M
(h1=tee;TALL THREE of me bllowinq)
` J WJe hereby affirm that me body Of the deceased does rM mMain a Mtlery. battery peck, power cell, radimi lmylent.
or radioactive device and that any auCh materiels were removed Orion W Me mecutim of Nis Autl mdOn FOnn. Fellers to mmove
,wr ,My�esa Memo prior to cem&Can may mouth In hmm Wmandatorym
Y cmatory and emmeWry parson not.
GPI IArm stflrmorminswNone haw been gteento Me* K. PaFl
regarding the removal Of any pemml property oromer Ming of value such any person signing below or any family member of the
dewamwisne.mpmwrw. Pine view_crematolrom
is not reepmsiae for the Fort Of Personal Items hwn We Container or tmm the remains Of the cemawd.Persons ttems left W Me
.Oconeemer or with me r elm wri t Wdesoaynl ON Me cremationm a Pcn and cannot be mMeved other emmgan.
Vry Me for authorize PideY Cre eWnum
re mmm the mmalno of Me deceased.
FINAL DISPOSITION
aT�efm�ira UP handsome me tPemeted remains of the deW8e from the wool is:
Name lbecove
Address. &IF H,.h o wf6al,, a, AN 1147, Phone: ,ci 7,4?4f 5(S
Tire me Wd remains 0 dismissed den be diµ Mof as ellowe:
(awed rid .�A.
NWr any re ism me Amon named above days nMeke pee slon of dry,rnem remans.
Pith Uewcremabrium N ickhouredl0giverponnsionM
theremeini a ery
bydeliv
pwsw MM-MMI
In person or Ey registered mail.
AMur A rhabM
�wowver Page 2of3
)OS11198,I(Rev. 0115)
Authorization for Cremation and Disposition
ad
(ii�i'' Me Aniseed)
C&AII Nee underabnd mnu toad remains am not calmed somin 120 domencremafpn.
Pine Vi vCmm Wnum meydispowdlhemmainsin
an lnatnevable mei such as by smUdng reentaLiP°^w
CREI ION CONTNNERNRN
`% ' N Mum to be uwd aeemMeinerlw Ne cnmelai remains Dada been Wrcoaeed M1om FNinc4
ard'm wondered ee follows: r i, V'dN1
Me undemtandtlet if de um is too small to lwid Me entire UOMSa remains,an nSJunal rigid anteiner may be used for delivery.
-0R-
Pn um is not your pumoased. More understand Net it no um is pumbased or Mnenvor provided
Pine Vi¢w Crematorium all peen Me cmmeled remains in
a rigid tempmary wmat er for delivery.
This Authorization Farm wads provided by Mal K. Parrish sexecute0at
aIn
CarIe1M Funerel HorOrne, Inc
88 Main 9t P. O. Ell 07 Hudson Fells NY 12839
and i5 signed by Me funeral nedw a5 wlmeaa 10 its a ms omen.
Me he" received a completed wpy d this AUMadmwn Form.
me pool dentified helow Islam Ms Pfflyl In aantrat d dlapaalbon, who 4 signing this Authorization Form,annast
to Me accuracy and wordlessness&the IMormation conYlmd In Mla Authoriza0on For and adM1Owelsl Me bingeing.
Mgnedhj fro wYd June 2020 AinzA � r,
Ce0oreM1Jaboopit ha�`/sY/� 1V 2(v
10 Best&t Box ]A HaMwtl NY 12838
rme.mmxw
rrw>wuwm
:
l K hill K. Panah
fiscal
AMur D. Jabot
OOS18gb11Rev.C&15) Page 3 of 3