Hollis, Willow Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745.4477 or (518) 745-4476
FUNERAL HOME: no rLM[Q RETURN TIME /�
DATE S TIME REMAINS ARRIVED AT CREMATORY: L 40M 2 A Ph
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
K46L 1Kvy t L '1
NAMEI JILLEW {�ptw CASE 17Da
TYPE OF CONTAINER: LI .:M I LN*Oi46 l+k Nf
PLACE OF DEATPo 00.1 pd1f 905frw I
ESTIMATED WEIGHT OF REMAINS S CONTAINER IIl
PLACED IN HOLD: A�
PLACED IN REFRIGERATION: Z DAC: 1
DATE OF CREMATION: GLIS Im
TIME STARTED: -I WAYI TIME COMPLETED: 91
PLACED IN RETORT: MOVED:
RETORT 0 IN WHICH REMAINS WERE CREMATED: fivl& fNVQ
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN AB HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG WALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORT.
New YOM crew
—r" ro Division of °e`ec...`e�
DMMNo O`CEMETERIN
Cemeteries 99We$M1„�13,,;�,
T.XINAMNY122e 6
Authorization for Cremation and Disposition
Th*AU do on Form must be compWd and signed finance delivery,O"almb cO Won.
Oam done 12,2MO Number: W
Crematory Name: Pine Vow Cematory
PCCrev; Oual RC-0ueanabury, W 1280a Phow. 5W46vs477
CREMATION Ia AN IMR ERSIRLE AND FINPL PROCESS.
Cremation is came]old by pMtlry the remains af the OYMBBM aMVR member holding do MmeiM into a cmTuticn CsmMr wh i
theyawsuLy WinbneehMt2nOname. This h and namewill Incinerate and eomums everything can WnssMrA
which am all a wm be Yx after cmmanon.
Following remember, tote mmatory will bar reasonable eROM to remove all Or the rwnaNs and older mMNl from Me wmdNw
chamber, but sane minimal dust and Mitlue will likely W 10 behind, The Crematory will WpmN,ntl end ll and enough mabdal M1om
the mmamsaMuse InaEwll androregnma"dalstillbedlspmedcfvrnguiredbylaw. TMc abdmmainsmdWmeM Wlry
pulwdzW iMo All pieres and oweed into a EeermW mnbirmorum. Cmmabdmmnsgbbmllyab Wln untilno
tlnpYingmemY ncognlyulB ie sWlBbl WaW.
OPENING OF THE CONTAINER
The cmmetay may only open Me wntaircr noting Me unuematW human remains In Ivnlmd arwmsbncN, such At to confirm to
Identity of Ne de sad firm ensure Nat n0 mamdal is model which mlpMiNure amployWs damage pq chemamy,property- If
human mmaiW am delivered in a container which Is not suitable fir cm "On suchW c0monlal or mental cal the
tommeary will require Matue remains ba moved into a suitable comalnors Nacwpb Ma remains. The openly of
containers tM transfer or removal MMmalns will be conducted bebm a Wmess and fell W done In whooy, wont dignify and rayent
IDENTIFICATION OF OECEIaFO
Name Of DS end. N910w HOIIN Maritll BbWf hbwr McTN
wtNW mu 23 2 C ae , A Aar
Made of Ceab: Glenn FeNa Hmeral.(all Ftls.W 1=1
sax: DM 9F Age l6ijODi Dabwo O 111202D Estmamdwaight ilb
Deschphon M®skevcontalror in Mich of veil [e delivered.
Minimal cremation conditioner
PERSON IN CONTROL OF DISPOSITION
(Porsm(a)In cx wadlepa m,Jog Corr Me nove )
amMbeM the dulgnamd agent of the Wuamd Oeaigmaidn a will orwritlen inetmmeMeMci E pursuanib Public
Heats tow Screw 4201.
-DR,
G12IMe haw noknoMedge their the demaawlareuaedawrlenIna entpursuantb Public Must LAW Samil4201ora
will meta ng dimcticns Nor to dinowl of his Or her remam¢and Its'a are Ma comoMq WN pMMy under Public HwMh sew
Must Q01 a no have live n A to soundness cremation of the,remains 0 the deommal Myl°ur Meuonshlp to MO d 5W Yae
roman:
Willow Hollis
DOS-t sheaf(Ray. WQO) Page 1 of
XU—NOrinflon for Cremation and Disposition
(inmd me rat Noted
Number Downpeon: A Wool Went
1. Apereon designated in among Wmuam m Pi room Lew Becton 0201G):
2. The surviving apwse.
L. The Surviving d0mealt paMer,
5. My suMvinB chIld common y M0l no or older.
<. A surviving parent',
6. Asurming sibling signal years otpe 0r 0Meti
S. Alawlully app0inted guardian,
f. My perna (s)sybean yours of age or older amend to seem in NB mail and wfo lI 010eM In mMemNp to fine fed:
S. A duty appointed fiduciary 0l Me estate
S. A Goan bond Or nUbve who has assorted a wlNM statement pursuant c Public Heats taw5e A0101(7).
10. A&W hall offer of a county or 6 puNk adenu eta appointed comment b the Schemes S CouR PmCMun Act
Its. Any Omer person who in a@ry an behalf of Me daceamed SM she has azsNM a whose 6bment pursuant b Public HmM
taw Becton 4201 m.
(InfuseP first of may romm !
L-0-1Mb nereNy oft that to body of be demur ham,not contain a ba q, abbey RO& power®I) =io=w implant
,
or ra Ioa dsuk6 and that any such materials wed Pot gi0r b see announce M Min AYMprhstlW Fmm. Failure N mmeva
abuse Items poor No cr aUm may mull In ham NO Me commonly and summary pononml.
CCMes affirm tat i1struchON have ham giKn to Merchants A.Gilman
reoeMing My mail Of any{ MMl pr MOr other mill of wlue witch any Pomon boning testes wary Ismily member of the
demesedwiaMebpnaerw. Pine ryes Cot q
is net msponsible tot me mnOval IN ma al Items room m6 control or arm be remains 0f the deal Personal Items eM1 In Me
container or with Me mai lm wall be dm"W by Me cmmnon pocese and alma 0s oblwad afar a rem wn a o
SICLL Me Mmby au oh Piney Crematory
to cmnaw the remain M Me dacusmd.
Inv rev Ocrin y
LYN handy somewhat du named funenl director to provide ter collvery b and MmNon by an alternate
mWry, IF dY necessary In the mnton of Me funenl director and b amend this tom to small me coma name and
addnu off such anybody crematory.
FINAL DISPOSITION
The wmon mMOnzm W maim tthe"Mm Mail of to dareaen]room be sweet e.
Nam'. M.B. Knew Funeral Home
MLmes. BR BO W I E ,frod NY 1382E Phma: 518-7I7-9266
Tf¢cnmaM remains of destroyed vnu be diommnd Of as Name.
ReWe bCassandra Halls
If for any mmn the pemm named above does not Wks prcuaelon of Me ve Wremains.
Plow Cremmwy geMmam he tow pmnee4onOr
gummy ma
tte Remains M.B. Manor Fumml Hone try dri very
peswi..mu
In person or by m:temd men. 4WIW Holm
mosommill 00ul I(Rev. page) Pre 2 of]
Authorization for Cremation and Disposition
(gGibigmeldimi
CALi understand that form remains wo not ciail µteem lzomnaf vem.ucn,
Pine sew:Comedy, may disease of they mm9iN in
mmneacmrry,
an mrstneundle manner,ruin as by auhtatinp.
CRE"TION CONTAWEMM
O nfrof ONE arms ldlowunal
An u m to M used M a Model far line vemNW remains has Men pumnaeed arm
add is dams d as dismiss'
INJe uMe9bW NettltM um I¢tin mall d Md Me entlrectgneM tpneire, an aldgmel rgd Wntynat mry M mood Mdellvery.
OR- Q��I
C if An um is not yes domineered. INJe undeaand data ff no um is fomMss or otlaetae pmNpM
Pine Yea C2mel wIII flow me CPomeletl demand in
e ti8id temporary renderer for delvery nanrocmm
This AUinimal/on Form was seeds by S hanleA, GIMan was normal at
M.B. Under Funeral Home dw•uaa
Bx directory Fort Eduard. NY 12MB era m+w xrrvl
and is signed by may funeral diremr as wider.d Rs exxuMn ado
IMb hal madevs a doorplate Copy of no AUMoidal Form.
no paaon(e) IdontllNd bal some W peaon(a)In commt of dlspmhMo.adds Ey signing the Authorization Farm.eMQs(
to 1M accue%and cmpsaenm a of the Infomatlm contasns In May AumsANon Form and auNOlkefe)the fmpohnp.
Signed the lee darof Jure 3020 / �
c A
Cassandra Ndse D��rA I _ ?
ado,
WITNESS:
Sendai A, Gilman
ouwtesvn�.twW F.«dh6
14163
Al Pass
DDS 1 il(Rev. 041 Plegi