Fuller,Gary John Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: OyL 1Mempt RETURN TIME:� �,t
DATE S TIME REMAINS ARRIVED AT CREMATORY: W/0-10 Z1 j6Qh
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
at krnp ehar
NAMED cal GUtz FS - ( f CASISES
TYPE OF CONTAINER: FIORAft (aNLf" r If bPII R LkY.d e ' .PLACE OF DEATHI SO U TN L61GE / N AT PsUEP M. OCCI
ESTIMATED WEIGHT OF REMAINS 6 CONTAINER /X1 /390I1r
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION: bAw
TIME STARTED: qA= TIME COMPLETED: ,yIy6phI
PLACED IN RETORT: 1 DIM MOVED: '..�' IQD:'..E' QOb /IFL IML�
RETORT # IN WHICH REMAINS WERE CREMATED: C6y.KA BIL
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOS SHALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
oewmm.nwsu
NEWYORK Division Of DIVMWMODCCE# MRin
owDhmri
"aft"ATY as Wa aM�Mn Avant
Cemeteries Nam 12>31fain
TN.wwwtsmwaaaa¢
Authorization for Cremation and Disposition
TIIMAWwbetlnnFmm Mu Wcom and signed plbrto EMI'/M ofrMFawbrw/n�m.
OSM:JUNE 15, MO NumW 20294121 / / J/
Crwl Name:PINEMI CREMPTORIUM
Mil QUAKER ROAD ODUENSBURY, NY I281 PMnel 516745K/1
CRE"TION IS AN IRREVERSIBLE AND FINAL PROCEBB.
Cremach Is cants out Oy parting me remains of the d&'v add the mMB' hopmeg Cher WM Into a a¢ wammbYwiMe
MC/ aze subjected to Intense neat and flame. TM heat and Mail will lWnMb and!co Um sae "aWpl Eats and moist•
which am all Mat WII he WI after crarNticn.
FrAlml cramanon, the uemercry will hae reasonable efforts to remove all of Me remain and Other material from tM u bon
chamber, but some minimal dust and residue Off nary M left behind The commons afn desperate modental and Iwelgn m mlm Vn'n
the remains and the madame[and foreign Mail via M des✓ Of am tail dy lax. The vameted remand vau M dMManii
NWwmdimo small pa wd placed and a desgmddd WMII'eta min crwNbd Ienralru Rananlly am puNMied WNlm
alle"am h recogn[aabb As mail Y m.
PEN NB OF THE CONTAINER
The aemalory may only open the tenderer holding Me useemendowdea human remains In bmRed amunetenxe suU as to confirm theN etnly of Me lased orb ensure Met no maedr Is endl which majo ran emplOyeea ordamage Meaeffai PmpertY If
human ninon ere de[iwrvd Ina cc ner which Is not suiti for c Won shim as smmOn[al per ranlal G"b Me
melory will spare bathe remand for moved Inb a manage COMi[re mRmedisp le Mail The o WIN his
cmtatwr or Me faneler Or remcval 0 meteors sill Ee wMud before a whorls and fill aft done In pnrapewth dignify and respect,
MENT]FICATION OF sD
Name OID as ,
GARY JOHN FULLER Melly SNWs'. WARRIEV
Iedt Known Address: 55913/11 LN(E ROAD NORTH RNER,NY VON%
PNm Of Odwh: 5641T11 LANE RD NORTH RIVER, NY ll
AM Elm OF Affli OOB: 04/0I/1948 DsleolD C8I132@D Estimated WYghl
DeYhpam. acask w=iner in which meat fell Ee"ry
FLORENCE CASKET COMPANY/CREMATION CONTAINER/ CARBOARD/FIBERBOARD
OF D SP05 T
(Porsm(al in¢mfmaaromnron,mna Us"Mm"ww"O
I anNVB ands Me Mwgr dagent a and asM dgglW in a add Or wimm mstrmM o-e Nd pursuam M Public
Hey Law 5MOn 441.
-0R-
by IpNe M1evenor Mebyrge Mat tMd and exeuheyand eta am Me mart apparel
MONPublic Health
der Law SRtro tinn 0Law
IIsonaini 1 nd hawsMMe to
of his Or her wmewre and Ilse are Me patella) Mvilg [tlomy under the
Matthews!
Law
Season G301 add have Me rigMlo aulhor¢e oamenn Of Me remains INme oxmsed. MyMur Matlommip tOdtatlewsetl Is as
blow
GARY JOHN FULLER
W61BgB11Rs¢ CYtD) Page 1 of 3
Authorization for Cremation and Disposition
Nuumbmb N er 2 rw Mae DescoW
OeatnpM1on; 5PW5FANFE
1. Aperaon designak4 in wring gMeoent M Punic WAIN Lan'Sedic A2%ISI.
y. Tlesurvlvup sFwae;
3. TWw ,NMesecpaMec
J. Any wfering UiIE epMeen year of age Of older
A Alum i9 Meant.
F. A awlvirq aiding egaen year of age or dWr,
6. A lawM1ery dryings] guardian,
T. mypeiecnlM eugMeen year W Age or dtiv encod 0 Mare In Me emi and v.M'Were Magat in mle4onsbip W Me aermred,
I. A awry appoiNm rwutiary of the ire
9. A tlaSe fiaene an reiaeve sand nea Reduced a v.Men statement purwam b Public Health Law$Val 4201m;
to. A 010 fisna Offer of a offers Of a pubrita'yfJnLSVatw apppntdf purueM ro Me Scrandi'a Count Procedure Ad'
1JL Any other human send is amna on Wren of Me de-eesed and and"a OANA Ma wTOen clalement MorWeM W Public Healm
Iew Sachos A2O1(yI.
rwA ALL THREE dMe Magresi
(ice IAve Wreby amrm Mnrtre WaywMem deed goad nmmrvanebanery, bemry pack pnarermlt ualwmve impMnL
or rodoeCive ae'nce add that any such malertdla everR removed prim W Me s hadown aMIa AUMMaetlon Fwm. FMIM W mrove
/ reseHHeme pane(o wemaloon may result In Nmr W the Moroni sM eras preoonel.
!/ w/ Age affirm NMlnMrvCOona have been given W JAMES P. MWERMOTT esav
regarding IN removal of ads pemrel proM Ry or tuner chirp of values MM my cercn vgning b9mv or eM hear nremMr W Me
decreased Wslue W prwsve. PINE VIEW CREMATORIUM
Ooaaaa`,
is nor reeduaite forth removal Of Manages!fiems had thin anWw a goal tM inB M the desand. Pmewaf Xeme W In Yn
�ows firer or each Me rumens Wll be dohoyed W Me crm m proceed artl cYmol W nhlavea abf cmnadon.
NNe Mrby auMorMe PINE VIEW CREMATORIUM
mem1rmm bwrraMtlw rmalm M Me MeawG
11nItIBI OPTIONAU
W.e lmaby wathavM W mi Mnerl dmMrb,provide for dMNed W and cmnadon by an aMemar
eaung, rimmed nnecessaryIn Ms OMnion o1Ma Wrong dirt and to amend Mbform b proide Me carectmmdana
ad
Mdress 0 such MhmaW crematory.
FINAL DMPOSMON
TW peon andecruied to racaive Me oemrM nme'me of gas a Bawd MOM Me asmaWry Is,
Rome, JAMES P. McDERMOTT OR EMPLOYEE
Aldus. 9 PINE S . CHESTEW0AN.W IM17 Ppyp; Nb ifll11
The mcnrM mnain al braawd wYl Ne acpwed M m fdMa:
Nkd IN African tl he person named aci don W rM pwuwl0 Ne rmmard renew,
PINEVIEWCREMATORIUM isvNMaa WM ywe% d
had remains W 9ARTON AkVERMOTT FUNEM NONE INC M dWN"
m wry
In person or Oy registered mail. EARLY JWNFULIER
pr.amms
OOS1886f(Rev.W311) Paget of
Authorization for Cremation and Disposition
AlI�IM/-a.6'oneri
1AAM ublarstane Mal If re remains are col Mymea Mnm 120 Jaya of utlnauM,
PINE NRY CREMATORIUM
J maY6apaaeaf Pe namtiv in
an nreNe241e manner, III as by srsnerin9.
CREMATION CONTAINER URN
/flnvolUSE Sale WISM f /J
(/ �! MUTIOMuse] •ONare M��tle/urn 'ia Me Eeen WrNasil
and 2 Jemlel as Ml . /'V , T
Me unee nJ MW if Me um M Me lm And un antrin NM remaira.an aOStiwW HOW ai9irnr may Be Mail MJNwry.
-OR-
Mum ie rwl yggaWwE. o5W wgaMaMtlulifrounMpaaMeM vatlwrviaepavl0.N
PINENEW CRFMATgVIUM Sill place the cremeleJ ramalm m
a HOW lamasary FamaWm My WI. Awmuu��
THIS Authashaa4m Farm was provides!try JAMES P. M LERMOTT Sea exacr M
BARTON-McDERMOTT FUNERAL HOME,INO. or�mv
9 PINE ST.CHESTERTOAN,NY 12817 nuw�ree
Isaw
SW M alglel by he Nn al Sinclairas Mress M My msXJrvnws,waw
WJe Have recawJ a mmplelen copy,&MIS AIMpInBpn Form
Thep oMsl iemUPeJ belwr Ware Me Mnonlsl In control of NepwNon,wha by Weri tlrM ArMafniMn Fwm,MISMS)
W the accurxy and cunpMspaa of qq Information canMlneJ In Vale AuM ytMMwb Fann And aNb ylari tM bre9gn9.
Sigrea MIe 1511H rWYM JUNE 2'0 y^ry
MARION Y. FULLER
POv BOX M s
NORTH RIVER. NY lMWB
Simi
WITNESS:
JAMESP. McOERMOTTe
r,,.ewwmr..y
123W
� ^vn G41TJgIN FULLER
MammorsW
DOS-1896ffise,. MIaO) Page 3 M3