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Stuebing, Jane Elizabeth Pine View Cemetery & Crematorium Quaker Road Queensbury, NY 12804 (518) 745-4477 or (518) 745-4476 FUNERAL HOME: aV.FMy4 RETURN TIME:DATE & TIME REMAINS ARRIVED AT CREMATORY: Platy .3.'Mnpv l NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS: PoNIFa KKAS NAME: PAPS 5TUft4)F // CASES �30 TYPE OF CONTAINER: `•�+Fq LF4+ f4v PLACE OF DEATH: 6i •IA(d qM3 • YA+ A � ' I�� - AJ /� SF. U h ✓ /� '1/J S' ESTIMATED WEIGHT OF REMAINS B CONTAINERIt6 :q PLACED IN HOLD: 3'4 1 O , PLACED IN REFRIGERATIONI DATE OF CREMATION: 6 2 Z TIME STARTED: 7* TIME COMPLETED: 9 PLACED IN RETORT: 79.�.- MOVED: -7a� RETORT F IN WHICH REMAINS WERE CREMATED: J )/f TC DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MOM THAN 48 HOURS FROM TIME OF ACCEPTED DELIVERY: _ NOTE: THE CREMATION L008MUL RE RETAINED IN THE PERMANENT FILE OF THE CREMATORY. lary York love Department of State o�W r Division of Dlvlslopail N.METEReF3 OF "RTDNm. Cemeteries or, "'mania r diu tww Breathable Authorization for Cremation and Disposition This Reparation Form must be completed and signed prlorto Eelwry of rosins AuthomMlon. pat 0hi1012020 Number. l30 Cnm=b Name:PIMVlsx CreM"UM Address:aabr Road.0uemeburr,W 128M Phone: I-I yf CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS. ChommMay are subpded m Intense bceaaeand 0amc the �as 0 the The hog and opera ceased and III I"mi wed ce mormener o Bume ven'Ntng exw bens and 1, which art all that will be left&Bar cmm Uon. FalWne oematbn.the crematory 411 ge reasonable efforts b All all ache remain¢ and other material tram Me uemahon chamber out gone minimal oast and mid"kill be tall behind. The mmalory will exparate incdama and long material from Wrvremain,am .elnb tie inaanW ew 9ntoe Wug e'iletlaonYiammaear Cmm dmmslmcremabbsnnpu"rl"aYYlnoo pixce nave Wmad pa MEY .male xsgment Is,.cegnlubL..eblwl us.ue. OFFININGINITKIECONTAINEIR The mmmb may only open ins container hcwirg me oncremated human remains in limited circumstances.such as to conNm me Sol of Me damesm at to ensure match material 's andosed which might more,amole or damage the agency property it human remains am"livered In a mmight,which Is not suiM1ble for conceded such sal cerem"Al or rental uekel,the fonnital hetransfer«remcvremains a laremaem late a before ataw ineessNaa whirl bee came inemivacv^with banked respect. IDENTIFICATION Name of Cemaead.3are annual steeds MarMI St s:Div Last Known nddmss152 SM an Ave broccoli My 1 MM Place of Death 152 shaman Ave.ovnabun. NY 12W Sex: ❑M ©F Aga67 DOB.. 09105/1951 Date ep o0611fil Edmatedweghh. 125 De.nnpnon aaa.BavaMMme,m whim remem.MII m a.Eree,e. Cardboard Chernation Trey lPMdn(al in m'now or dxPos ONE Of the lovoMrp) I antral are me dmgwtd agel of 1M deoneW design in a van w wdtlenistimem executed ponuent to Public NmM Lew Season 43o1. OR. IWO have no"nowlmea that me dawasN exacted a valnen investment pwaaedw Public Nunn Law Surr 4201 or a wl' mntalmng mire na for me deposition of tare 0r her remains am IM am ins parson(¢)having prlomy under Public NUM Law Becton 4201 and com to right M aNMrin cmmation of me rsmeire of the demesBd. MyMur nlNlon iblp to the denai Is as fallow Jane E. Stuebing Page 1 of 3 ppa-0BSBJ(Rev.W40) Authorizatlon for Cremation and Disposition (1"i from me 9M baow) Number:3 Deunphirr, Daughter 1, Apeman an1mpul m wrong punmmer Pudic Health Law Saar 4WI(3): 1. TMMVMrq apOuw: ta. The aurvHing comedic partner a. Any suir cMl0 eighteen years of age a alder, 4. ASu iNy par 5. Asurverm aim'na eleht",years of aye or older: 0. A bwfulN APPOIned assumed. T. pry merchants)spurred years of Myer Or Older argued try share in the Halm endw00 ielem ckeeel'm relal'mmNpb the de[maedl e. A duly appo had gtlucary of W eaten: 9. Adoes mend m relnllve she has m bi a vrtltlen albmeM pul l to Pudk Hostler Law SMon 4201(7)l till Adref feral OXlmr W a money or a publ'i Administrator MWlnld pursuant b me Surrosom 9 Covet procedure Ann 1M. Pry oNm Made wer a amine on halt of Me deceased and act,has endued!a wmin Redeem pumant b PuMk Heels Lew Section 4201(7), ( I ALL THREE of Ifs fradmin9)Me thereby Which that Me body or the demand does not cousin a bli err battery park,power roe, reflool indi Windstorm devM and Mat any MM Motorola ware Pull Oomb We"wevoton of this AuNmkaflon Form. Fallun b nmow than hems pdor b cremation may neon In ham b Me cnm q and crnmnry Mmmnsl. ,d Me anus her instructions have Men given n MaM H, Parah .. . � reaaNirp the remwdl a any mrst pm�m mar tNrq etvelw wTkth any Mason aMming Wow or any merely mama a Me Pine V'aw Cmmmmm d and Mahe&b Morris. is not responsible Mr Me beho l of personal lama hcm pro"Winer or from Me contain of Me desand Personal Mma left In Ms curentalmor or with the remains will be deso d by the cremal prowl and canmt be MriMd abrrnmatlon. Me hereby authi Puna View CMMrt Um y f over npem.la Me nm.In.WAve aeuuaa. Lit rnsumpureavo f µso honey mithodw the named funeral mntlor to Pmvlde be lNlvery he and enmanon W an alternate e retorel necessary spin Ion of lb fuwnlMntlor.and to amend thisbrm to Whereas Me deal name and autos m mamabry. FINAL DISPO SITION Thep tMriSW Mre w N4 mmww means of Me loos MAY Me arm 'In Name: Carson Funeral Home, In Ask ia:68 Main Sill Hudson Falls NY 12839 Mom., 518-741 The aemawm im MMau soli M dlaponrl Wnbawn. RM m to the Kml If be any Hudson the prevent named above eon rua1W paau nMthe mma rd im. PM rem'Cremasomm is wM non pMaeetiona Me earmbs b Cadeln Fumnl Hmn, and ever as dy theory In person reby rpnbrea el Arw E.SMtal r�wmi Page 2a3 Dos-189eN(rev.lanm Authorization for Cremation and Disposition III rate kdowinal WJe usAenuM met K Me tMains was net dol »thin I days W Wma , P Mho,a few Cmmeodum may dlep 0Met iNM anmainf ame memo',wil,as W scauenn9. ro�✓a...n f mm�oNE wma amwM91 1 \A An cm to de awed as a mmelne,m,Ma cemard rem.Me has Milan pmu+ased from 8+4v+-1 it, and IIss Montreal as talons: L.w OA.. a.i IAw,uncetrond that If Me an is W smel b Me Me whom atenuted mmein, an eddis di Wnmmn they No k,dtlNarv. ay. an is rot sho pwvfiaswe Ime cndarsund MW N be am N w,unated a,alhwai provided Pine vow crenwt m Mn Now Me crtmated nmMnsm nM Conrada tqk temporary Comumrtb Novel This AUMOm60on Form"a provided by Me*H.Pedsh �yp4M� was eascNa]at GMIW Punched Homes 68 Main St. HUMcn Falb,W 11839 6uuxx andb a0ned ey Me bra l director as witness tots asemaon. Me how owned a combined copy of Mls AUMONUPon Farm. ftion,who by Form Iph%acovwy and cmplNnbalm ews,W Me 1Mmmatlon cmtalned In Mdea the promentims)In control of b AUIM, Om Form and eNvemos)the bhpMing. Milmlthes llM aYd June p30(� Jody Tawlar y(1 o176 therm St.m.hawfirrit, 1.Gore,rate NY 12801 A� swd w. ati" WITNESS: Mark N. Pohe� 12872 n w � ryymM an Jose E.SlpeFq Page 3IN3 OOS-1893{(Rev-O<YLO)