Dougherty, Ann A Pine View Cemetery S Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: �) 1) '� _ RETURN TIME: tg071
DATE B TIME REMAINS ARRIVED AT CREMATORY: ( /ILI W 7 PD h
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS'
SACAM Fusco
NAME: _ APO BDJ411M CABER 72&
T
TYPE OF CONTAINER: ^W41+ ' • f iN 1In �" Ai(•
PLACE OF DEATH: 23 y r 1 II ITSZI
ESTIMATED WEIGHT OF REMAINSJB CONTMNRR Iu IPF
PLACED IN HOLD:
PLACED IN REFRIGERATION: Z'/j�
DATE OF CREMATION:
-F 4-/3- L Z
TIME STARTED: /4 TIME COMPLETED: 12 w
�GO 4 03
PLACED IN RETORT: / 'b✓ MOVED: I/�� - I�f_•�'�I Z�
RETORT R IN WHICH REMAINS WERE CREMATED: Re, ar /gypw 4
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE, THE CARNATION LOG $HALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
back York suite
Department 0 All
—J NEW PORK Division of omsloO OF rCommrce Plate
BTATEOf One Commerce RPlate
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owoRruwTr Cemeteries 99 Washington Avenue
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Authorization for Cremation and Disposition
This AUNsorhWm Form must Ee complaint and SISM qbf b Milli IS AM
Date, a8/1112020 N~, 7 Z&
Care"Nam:Pine View Cratllaionum
Address.51 Quaker Roatl Quarkarm ry NY 128" FMne: (518) 145-0Q7
CREWTNTN IS AN IRREVERSIBLE AND FINAL PROCESS.
Cnmetkn is cameE oat by placing tar remains of He emeasee and ate container holding the remains into a entrench chamber whom
Cq are sWledW b intender heat and flame. The hear and theme will Incinerate and conaurM sWryMlrq Al l Wrw anal bll
welch am all that all M NR alter chamber
Fulowinp bemaeoo Me crematory will take reasonable HbnS toreo w all dthe remains and other marerialhw formaltl�n ate ema
Mender. but mine minimal due and revalue will likely W Ind behind. TMcreinal will reform normal and foreign maternal Man
MeremainsaMMaindenulaneroreignmatenllmlllbedmep dasreouiredby Nw. The uemdee remains will W machinery
whenever into unau piema and planed into a designated mnteimr or um. Command remains Sanarri ere pulverized until no
Nnete hvpmanl is rwapnhable as symbol N6 m
OPENING OF THE CONTAINER
Thecrememry may only open Memember homing Ma uncovered human remains in limited urcurrsun el an& as to confirm the
&ruby or Me measured orto ender Met no miser is enclosed which might injure employees d damage Me crematory moral. If
human remains are edherM Ina conYlmrwxlch a net r ulubla for cremation such as communist or rental call the
mnmmorywille uim MNthere lmteamavee ImoasuftWconlalnerbefore NaccoMNemmim. TMopeningota
nmmerortheharmferornmovalofreinedwinbewMu ceforeawdneasaMMIIMdoneinprmxN wtlhdignMandmpxt.
IDENTIFICATION OF IEEASEO
Name of Normal Arlo A. Dougherty Maribl5btw' Wedmore
Last Prawn Address.23 Morgans Larne, Q Mfstltk, NY 12B21
mew aMmM 23 Martians Lane, Comstock, NY 12821 ,�'n
Sae ❑ N ® FApe: 93 DOB: 01/111192I patedoeetn: 08/11 / 020 6nmar mw:�
Oewpdpn d caeFaVwnglner In which remains wil WMakers,
Fiberboardmitemative container, MaBhewe Company
PEPSON IN CONTROL OF O SPOSR ON
(Problems)hruseful kkcwp ell briar ONE dare Raymond!`I 5D fi" Ien oomtheeevgna agemWMednre desg dinaNllormftnlnstmu teeeCored punuemb Public
r H Mlaw Server 42Y
OR
INie have no knowlM2e that the ee¢aal esewlad a women instrument better to Pudic Health Lew SMion 4201 or
will containing cerebral for the dispCailim d his or her mean and Ind are the"Normal moral parent under Public Hearth Lax
Breach 0201 and he"Me night to summer vema0on of the remems 0 Me moment YylOur M ommp m the deceased Is as
ftiw
Ann A. Dougherty
D05169841Rev. oaF201 Page l ol3
Abithol lon for Cremation and Disposition
(raen Born do rv'✓mxxl
Humber_ 3) 3 oe¢omn:Survivina Child
1. APoreon marginal in wintry normal to Public Hall La Sa.Va 41
2. Tle¢uMMne spouse;
Is. The surviving caneGi barmen
3. My wrcNmP chilli agreed yaara of age an older;
l A•ul parent,
5. A ouMnng sibling batteed years 0 Me or older
S. A lewbOly appointed guardian',
1. My Poreon(s)adhaen years of"a or shot printed to share In Ow"l arm"a ware Regan in reaOmil b that Maxwell
S. A duty appointed fiduwry of the annual
P. A Uoce M1rontl ar ways who has executed a when slmemem pursuant to Pi raelM Law Sesson 4201(7).
10, ANiar boost officer of a county or pub io administrator appointed pursuant W the Social Could Procedure AR
10s. My other person whe la Suing on WhaH of be tlewsW and who has emoted a written statement purnsuM b Pubf mouth
Law SMion 420101
�{ (nag ALL THREE of the loadvirl
P` S I/we he lady affirm inn the bury M the m ddwwwa sows not wntai n a battery awry call power deal.radoal impact
or annual device and Pat any such mmeuims were removed prier to the emcNbn s this AUMa(m Fam, FeOwe N remove
y tlrNB XNrb price to cmmtlion may was up In harm to the cremelwy and annual mid mi.
4 owe Wind that massaging;have been givenM Sarah Xawwa Philip
�a regarded me removal ofmry Porsrol pobeM mother thing olvabrewhkh any parson sgning beta'orany tardy rartllel
desamed wishes to pm¢ e. Pine WOw Crematorium
�¢lid reebanable brtM remwel W Por¢mal Itemshwn la mnlainer cwww me mmain¢oltM deaaaed. Peraensl IM1m HX In Me
coaatnar or WM Ins,mmalne will be dwbdyed by Me eremsdon booms and unrrat be reWavad•Mr cr•meMon.
,� 5 �I IrxaaMy•unwae Pine View Crematorium
Ki+ww b cmm•btlrs mmaia of dw de[saad.
f�opnawu
LMis hereby•oal to nodded Nnm ton to provide Mr delivery to and emmatian by an mumme
overseas, N Mail aeae•ry in Me opinion at t and director,and to amend this form b provide the wnM name and
Mdw of such attemate crematory.
FINAL 018POB1TpN
The added audwdlM to receive May CR remains a Me decreased fircal"advisory is
Ned Regan Denny Stall Funeral Home, Sarah A. Philo
Metal 53 Quaker Road, Que trsbury, NV 1280y Pnpne: (518) T82-1114
The managed ed remora of deceased will be dolmas of be ftllws:
To b s resumed b the family
IIM•m rash me peon named papers Man;mt bow coastal s"and nmeYu.
Fine View Crematonum a w,nmimd m glre poseessim of
,Rest De
has remalnaM Ragan Denny SteaoN Furegral Horlre by set'nay
In Porecn m by regaMed man. Mn A. Dougherty
pJ It t(Hw.got real
Authorization for Cremation and Disposition
larall So
Somali
� NNe Wawalaa Ma dMe rent.ha.in nammmwimm tza esye aaenwl0n,
Pine View Crematorium may depose of Me remains in
on lnem manner, need n by pool. uwa+m
CREMATION COHT.V N ERNRN
(A ME of the havoleimpo
An one w as Weed«a(variant day emotionalmmairrs pas boom purcnnad font Net Denny StaHON Funeral
am in 6sArKE as MI
Ii untlanland May d the an he W small b MIS has en4R tlma Rmyns, an WM Mid mMandr may be ul or delivers.
oR
Xmi• N patl. d I undeaWndN ifmumiapaWue]a�pmN
Pine View Crematorium Mil pew me aaootel ramama
a Mid temporary container for artery.
The ANhah•aon Form was postal dry Sarah A. Phllo was completed
Regan Denny StaRad Funeral Home
83 Guaker Road, Gueensbury, NV 1251
aw a Ypmd Ey the funeral dlrecar as addressed In its ezecWon..
IN/e hared received a completed copy of this AWIFwlaeaon Fart 1.
Th•pr•mpHdemiRed below often that penoMsl In cal l of dapo•iton,who by signing ads AUM aem Fain,•ffial
fo al acpursysra amplaeness of ms Information complained In MIS Auarorlaaaon Form and•Nhorlmtsl that N.
MgnMMb 11th day of June , p 20
Sol M. Dougherty
23 Morgans tens, Comstock NV 12821
Denise Hart 'P*,e-1cIL_
102 Salem Street, GreemncM1, NV 1283d
MOIIIESS: ^ _ /i
Sarah A. Philp Ts ,/pal -I l�yll'.`rii
v�.-+or.mm.�w.a.rww
12889
AnnA DoWheM
w-..awe
Wet 8W(Rev. 04120) Pegs a Aa