Risser, Phyllis Geraldine Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 7454476
FUNERAL HOME: _ eAE*xw _ RETURN TIME:
DATE S TIME REMAINS ARRIVED AT CREMATORY: IFIT(ro 3m111
NAME OF FUNERAL DIRECTOR OR REGRISTEREO RESIDENT DELIVERING REMAINS:
Da EEd KV6116
NAME: PNYLLLS Flgf& 1 CABER 131
TYPE OF CONTAINER: M #iD,,F Lfla, �� I� �h—1 '-`
PLACE OF DEATH: 13 PAV UDL.OI golpi "la>- I M iv5
ESTIMATED WEIGHT OF REMAINS & CONTAINER &D 'M
PLACED IN HOLD: L,
PLACED IN REFRIGERAT//I--ONS 34 �' I
DATE OF CREMATION: Cp' S'2
TIMESTARTED: I TIMECOMPLETEO: W
PLACED IN RETORT:' MOVED:
RETORT # IN WHICH REMAINS WERE CREMATED: 61,f r PION r PA k
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN " HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOA SMALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
e York Sure
////--��-�lII Department of state
EWYORK Division of °IVI9'O990[CEMETERIES
Arthen
�\ STRaDr 99 Washington ra anus
°" TY- CemeteriesNylnM.ddm
me'.1518104d226
Authorization for Cremation and Disposition
They AUMorlmdon Form mint be wmpla" and signed prior W delivery of herein for cmnaYon.
Dee: iJa n cz IIy 2010 Number:
Cramamry Name: pine view CremMrlum
Mdre S Quaker Roved Quesensleam, NY 12804 Phone: (518)745-ill
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation is carried out by placing the remains of the Eaea.ea arm the container not the tamer"into a cremation c ourbor Where
they are subjected to intense heal and Mme.The MH and Rome will inclnenb and comume everything women bona BM metal,
which am all thR will be bR after cremation.
Following Werrapon,Me crematory will eke reeemeble egana to a all of Me remains and other maledel tram Me cremation
NambIN,but same minimal dual and residue vnll likely be left behind.The mmeMry we an"raw modernist and kreign m del from
Me remains end the Inalaemal and Melgn marenal vnn be disposed of as wall by lots The cremated remama hen be m anlmlly
Involved!m me small plecaa and p18ad into a designated Woman a um.Cr aW remalno generalh are pulvedmd until no
single m9mem he mcognin Nor an e W ION aeeue.
OPENING OF THE CONTAINER
Themm mmemaamy open Me container reading the materiel human remains in limited orwmaMnces so& es to schoolMe
identity of the removal or to ensure that he matenal is ermined gr itll might l njure employees or damage the turnery Pascal If
human MMIM en delivered in a cony liver which Is not Suitable NO mmadon such as commit or moral mit*%the
oratory will raquln Dart the remains be moved InN a sulleble"me nor before Namepb the nmelM.The a"nlIN of a
container or the tinnier or removal of remama will be andumed before a witness and will be time In pMery,With dignity and moved
IDENTIFICATION OF DECEASED
Nemem°eMased: Phylfs GeroWne R;sser MadMl Statue. Mauled
LeNROWm Addres6: 23 Oak S1 Hudson Falb NY 12839
PlareafDopth23Oak Sweet. 23 Oak Street, Hudson Fells NY IzpS
Sayer Q MO F Age: Be DOB: INIIII935 DMeMOeath: 05115020 Estm WegMl
Desorption ofcake✓2nteimr in whitll remains wall be delivered.
Ma 1411s Crr m<hon Ca say fa�waoc�
PERSON IN CONTROL OF MSPo ION
(Wram(s)in cmtmf NOHposilim. NNWONEWSre Nowing)
whi am the designated agent IN Me deceased desgn8ted in a ank or Whiten inGnmem outcome assu e0 Pubs
Hmllh Law Section 4201.
OR
INJe he" no knowledge Met Me daeased ebCWM a vnilkn lnsWmed pursuant to Public Health Lee Sermon 4201 or e
Mining diMmions be the dispokon M his artier remains and are the OmCn(s)henna facing under Public Health LAW
Section Q01 ON have the right N authorise nomination MMe remains of the demesed.MylOur miadonship to the deceased Is as
follows:
phylfa Geraldine Rl
Mrmmd 1
DOS-181184 gar,.m S) Pagel W3
Authorization for Cremation and Disposition
(fp 9d them fee ear real l
Number-7 0eecnpbon'. P./1 C 6-u �de j✓
1. A mason Oargin in wrien8 purtmnt to Pudic Feel Law SwA0e 4301(3);
2. The euMNng spouse;
than The auMNng Gomeetic partner
2. Any surcNNg dead sigdeen year Ol age or Order
e. A surviving parent
5. A survrviy sibling eighteen"am of age Or Orden
5. A lawWlly appelnted guaNion
L Any person(s) eighteen yeen or age or Order entitled to Share In Me added and who blare deaeal In reMonship to the dews»?,
S. A duly appointed fitluuery d the"been
5. A dome friend or rel"Ohm a,w t ]a unben statement pursuant to Public Health Law Semio, 4201(7).
10. Adust rain officer or a munly one public edmmimnror appoined annuanllo the 5urmpalds Court Prrc um Act',
His pry Other"man"a is acting on Hal l the dewamed and who has exewbd a written statement pursua0110 Publk Health
Law seaim 4201(7)_
WD-If//Vg enA��a�l ALL THREE of(be ldlowirg)
Vrm
IMb hereby aMrm Met the bray of Me deceased dwa nor contain9 bN ow, battery pack, per al, radioactive implant,
"'''ormoraac4ve hall and that any wet.materials were removed wor to Me emeu4an of this Audwriutl0n Form. Fa11un to bring ova
{tthheemeenm
Items
prior ca0on may result In harm to Me cr mMry and cnmmWq panonnd.
V
I2rt P IANe afnn M al lnabuNons have been given to DOREENS yfl
regvartling the removal of erry penoml propeM or diver thing or will which any"raw moors;blue or any family member of Me
deceasedweirestoprewrve. Pine Vew Immawdum
is not reeponalwe be the renrovd of personal hems from the wdamer or mart the remains a the dawned. Mramal Verne tart In Me
container or wish Me remains will Wdwhcyed by Me arematlan prieesa and wnnM be rM after wmanon.
00�0—uwe herby authorize Pine View CreMe um
W mmab Me remains of Me dw rl
FINALO MSInON
mop ' . °
Name 1l � r�«eQlwM.n vesmnealAed r.m.ima�_u e d_awsaed rv�o).m ue cnmaeoyia:
� A
Address � p ✓na �n t> Pa Ns Ph 7y7 yz43
The cremated remains of dxeawdrwdswsw o rmfviones: j2Fsd
Lve / 4w 1 ) 1y YI
If eM wason Me wraon named above does not possession arms minted remains.
Pith Vlew Cm"Wrlum boulMr¢edlogNep $$Strad
MeremaineW cal
rl I WdoiNery
in person or by reg maned mail. ✓
phN Is Dera=Risser
El III(Rev. OW15) mw+�nnwrwa Page 2 of
i
Authorization for Cremation and Disposition
O(I an
rWaain9)
IMle understand Mat NNe remains are not chimed within 120 days MGemetlon,
Pine View Crematorium mryEbposeclMeremalnsin
an lrreNevable manner. such as by aeatkdnp. rcA.�.pn
CREMATION OONTAINERNRN
\� —
�1 An um to be used asaccnbinerbrOw cumMed remains has been puMeWhdn
rV6:h disdeecdbMublMma:
IAe understand 01et if tM um is We small an hold Me Who cremated remains,an mdaurel naitl consumer may the a for delwery.
4DRR-� /�
O ��/Anumusnotyetpuschum d lMeunderalendthMdnoumis Wrehae9ddoN mpmAded
`� Pine View Crematorium WII plan this wsmeted remains in
e rigid Mmptary wMainer or Merely,
This AUMonzatem Farm was provided by OONEEN6 MICAS fees emceed at
Carleton Funeral Home, Inc.
60 Main St . P. O. Box 67 Hudson Falls NV 12039
and Is Ined by the funeral director as without to io exearwi.
lMe have received a computed Mpy Of in is Authorization Form.
The personae) Identified blow ielare Me pe n(s)in control of dlepaertlon,who by signing this Auffia tion Famr, s11x99)
to Ma accuracy and man Overseas of Me Infarmalam money nod In MIe Authorization Farm and euNodze(e)Me fangNrg.
9�lgymd Mle 11 tlay ov 20 /
977ak SF , f}u Swig/ -y 7
mwd•r.. /^�
DONEas: �rn
OONEENS NINAS
::ZL2
Phyllis Gerzldine Palish
OOS ISM f(Rem, wi Page 30f3