Blanchard, Kenneth V. Pine View Cemetery & Crematorium
Quaker Road
Queensburyl NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: f8 A(TLMOP RETURN TIME: Sy,
DATE & TIME REMAINS ARRIVED AT CREMATORY: 6hro 7.00m
NAME OF FUNERAL DIRECTOR OR REGRIISTERED RESIDENT DELIVERING REMAINS:
PWA KAM6(
NAME: kEN11FSlI BrrLNYUAW CASE IF -734
TYPE OF CONTAINER: A�q
PLACE OF DEATH: 146 2EFlP Nq. Ar<Tl. N �2:SWT
ESTIMATED WEIGHT OF REMAINS & CONTAINER hs ar
PLACED IN HOLD: p�
PLACED IN REFRIGERATION: Z'70 P1R: ,DATE OF CREMATION: U(& (
TIME STARTED: g EIAM TIME COMPLETED: /, (MI )OpF}Y.�I
PLACED IN RETORT: Si yn An MOVED: l� Yo /L1 i0�RY�
p�p �� p� T , 4�
RETORT S IN WHICH REMAINS WERE CREMATED: 'EE]L�1•ay 1C
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELI VERY:
NOTE: THE CREMATION LOS SMALL Of RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
Deped..m m asne
NEWYORK Division of DIVISIONOFCMUSRIB
sAEw
°"" "" Cemeteries 90.
War 9m°^rAli
Atli NY 12,31.mm
Twerp toe i5wa4M 2M
were de,nero,
Authorization for Cremation and Disposition
This Awm &Mon Form must be complx and wgned pnorb delNgOf mmael for cremabn.
Quo06norm2D Number. 74
Cr""Nerre..Pare View Chancery
PLdmu:21 Ouaker Road,Oueenabury, NY 120N Pmyw.51674BH11
CRE"MN IS PN IRREVERSIBLE FN° FINAL PROCESS.
Cremalion a rsmed out by plating Me min ins of the deceased and the mrneinm hat the remains into a downtown dnmberebero
May are subjected to In@nu heal and flame. The heat and flame all inswe - and wnsuma everything sxgpl bore and msYl.
which am all that will be left Offer cm ation.
FWowing cremation, the Momaery win take reasonable mom to remora an of Me mil ins and Other mammal form the cremation
chamber. butwome minimal dust and residue will"only W lea hiW. The«amatorymeww WMcidentalaWforegnmaadalform
the remains and the incidental and foreign maternal war the disposed Of as required by low. The oemated remains all be Malawi
µNedmd into small piercers and placed into a desgnaad mntsinar«him. Cmmaw mmams gmemly are Punerlaad until m
single bilateral is emotional Me akeleal nwue.
OPENING OF THE CONTNNER
The crematory may only Open the common hadmig Me 0ncremaed human remains in limited dmumsena . eudt as NY confirm the
montlty of Me demaaed Or a onaure Mat no maternal Is Mounted W11ch mightinjure Membrane or damage Me cmmato MNp . a
human mmuns am dellwm In a container which Is not suitable be cremation such Me ceremonial or mr twskeL the
amatory will require that Me remains be moved into a&unable container befom d auepb the mmelns. The opening Ma
container or Me transfer or no weal of remabs will be conducted before a witness and will be done In Sm ll with dignify and raarect
DENT F CATON W DECBASED
Name IX Dewsed'.Kenneth V. Blandrmd Mani shim: Named
Latin Known A61ea'. 1462 Cwney R 49,Award,NY 12809
Nam of mlaws Counts 49.Ahgsfe, NY 12aw
sea: ®a OF nge:e"iDOR:DR122/�19��a DommD@aMo�o Emmmd weghc 175
oascnption of kWwm ner in which smalls;Wll be defiesred.
Florence Cremation Container/ Plywood and corrugated cardboard
PERSON IN CONTRM°F dSPosf11°N
(Po (s1 M cwbol GM5 ,, i=a(ONE W arm M N)
t$MMle am the desgnated agent W the dewawd dwwlgneted to a SON Or vmN IreWmem euc pursuant to Public
Health Lew SeGiW 4201.
(M
IWO have no knowledge Mat Me dewased exmuM a"ten Wrument Wmuentto Public Irwin Law Section 4201 ors
Im anMRg directions for the dis ix n of his or her remains and had ere taw or n(s)having prcNy under Public Health Law
S m 4201 and here Me right to authorm cmmffion of Me remwins W Se demased. shonur maNOMM1 Its ill the dewamd Is ere
Mbwa:
Kenneth Blanchard
DOS-0696f May o4120i Page 1 of3
~ Authorization for Cremation and Disposition
(In art MOM the hst bomi
Number pppididi: The SUMNnO Spcuee
1. A perBon deagnalee In writing pursuant to Pudic NeaM law Sececn i201(3);
2. The surnme sprds,
2a. TM surviving eomi partner,
B. Any surnard child Indrawn years of aged or cake[
A A Surviving Parent
S. A suromng seed eighteen years of age or deer)
S. AIdea lry appointed Moral
L Am Poram(s)eighteen years of age a older argued to share In Me more and who game Oman In reMbnship b INS damsae',
B. A duly appommi fidudary of Me serer:
S. A dwe Mend or native who has execute a"Ban statement pursuant to Public Haven Law Section 0201(7).
10. Achef fiscal off¢Brof a county or a pudic harangued appeared purauant b Me 5unodue S food Procedure Ad.
10a. Any Other person who is ailing on bei of the dtteaaed and who has maatd a written slate MOM purwuant to Pul Heats
Lax sad'nn 4201pl
di ALL THREE of N e Achowma d
Me hereby aum,Net the body MtM deceased does not contain a battery,battery Oak, power deal, mdw fib implant
orredma live device and that any Such Materi wive removed prom the ewagbn of this AUNorm ion Form. Facture to remove
N lure prive to CMMMI n nrq rdi In harm to the aemma and mmatory pwnonnet.
a,_ ,Map affirm Nat imommons have bean given To T rod y Murphy
regarding the ren oval of any Personal IurMerty or ONBr NIrg of value which any parson signing Ceaow or ary family member Of the
decode] wishes Be peserve. Pine Viex Cremaay
ie nM responsible br Ned remortl ea perecnel i1Bme M1om the wntmer or Boon Na remelris d Iha dewa»d. personal Ileme NR In Ned
coMalmr or with the r na x111 be aphoyed by the cremation process and cannot be MdeWd met mm"m
a-_Me moray auth ands Mine View Cremalay
� ww heerenreae the imof thee ea.
(Midal OPPONAL)
Uwe hereby authoaw the named hurvera director W orwide Bar uerwary to and dremation by an altmate
Mabry, If deemed necessary In NB opinion ame amend
director. and to amend this romr to provide Me comet name and
address W such albmam mmalorv.
Fl DISPOSITION
The pason school b mmM1e Me damaged remains Ot Me eedwaea*am Ne crematory,is
Name: MB. Palmer Funeral Home
Addral 02 rrmaway, Fort Edward NV 12828 pboM: 518-767-9l
The demoted resent 0 damaged wal Be dKpOeBd M as buovrs:
B.H. Soodrach saagoBe Nadvornal Carl
X teeny red NB poan named above droa rM Wife p Won of the demoed resins,
P eVm Crenaary IS aullooded Be glue pmseenan of
Have
to remains b Elk9[aN aUrchard Addevery
In person or by Rgutwee and. agavel SlanNoM
nAmawuw
0pS-1BBOf grew, "no) Pegs 2 of 3
Authorization for Cremation and Disposition
fM ft M'bwtaW
AWP"tM'e unaenstand that dime modern we not demand wind ton daysattanuuon
Ron One,Cnmatary
"wee may dowse IXMe mm.im M
an irmtXewble manner, even as by SMt ng.
CBEMATIOX COMAIXEPNNX
(lnlflal ONE o/bre Woeing)
M um b be seed as container br Me command mi has Lain purchased from
and is described as follows'.
Me understand that NMe um Is bat small to Mtl then eMR onemabd seems, an a-yHpral NO container may be used for delivery.
-W
�An um is not yet puraamed. Me undemreM Mat if no um Is numnamel or oMamise gwNea
PIre Yew Crematory will place the cremated remains In
rrr.✓o..rq
a ngia temporary container for aellvery.
This ANM1O/Izafion Farm was pmviaed by TirtgMy MuryM1r was exewtea at
Ellmtein BlentlmM nuV• amwxxne
rnmsnw
W Somebody. Fat Edwad. W J=bS
pu�wwnnu...r
and is signed by Me Nneml dinner as mends M in exxutim.
Me news mwrvea a cemented copy of this Augmentation Fees,
The Ponanpt Wentlfied below imam the payments) in contest M abdomens,who by signing this AUManntion Fem .attpt(s)
W the ccunry and complNarmas of the Information contahrrM In ends Awhoriza(lan Farm and alimm ten Me forpaing.
SiBnea Mist day or June ath A)
n,w: Am Blanchardlady County Rhode 49,Agyk, ton 12W
Wnei e
Timothy Mury�hy
12M7 r vsmmwv) Ins/nor //�
twami
ItenneM Blanchard
Iasam.rr
OPS199&llRay.0012f11 Ppe 3IX3