Simpson, Esther Pine View Cemetery & Crematorium
Quaker Road
Queensburyl NY 12804
(518) 745.4477 or (518) 745-4476
FUNERAL HOME: 0 Ci .NEO RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: . Wa Ito, 2:IS rfI
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
_ I+ et Yr._Iw F
NAME: EST{tK/ 3SgMPSR I� ,1 /� CASE IS 72 )
TYPE OF CONTAINER: L t5Le avowj II &IvU I�yy TTCC
PLACE OF DEATH: Is—) lr4W STW P" p fpf R 1 M I�71
ESTIMATED WEIGHT OF REMAINS A COMMANDS_ I76 dw
PLACED IN HOLD: pFn
PLACED IN REFRIOEMTION: 2:7u 11
DATE OF CREMATION: (T5-4020
2
TIME STARTED: �� TIME COMPLETED:
q'Y y
PLACED IN RETORT: J-M MOVCO: T' a Y
RETORT # IN WHICH REMAINS WERE CREMATED: 5.,1-Y / .A/I pk
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE "AN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY: _
NOTE THE CREMATION LOG SHALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
Downw�York
ofmay,
NEWYORK Division of OWIM OF CEMETERIES
SarurhoaT°uxlTY. ewa.n lyowlaw
Al
Cemeteries Ma Mail
Many Ahf4wwrm
were di am
Authorization for Cremation and Disposition
This Authorization Form must Sa compla as and signed "or to lalirary of remains for transition.
Date:June 12, =0 Number 17.7
cmmtl Name:mmV Clxe
Md.. (husker Rd. course ury, NY 1150t ppmy. 6f6]i5-MT
CREMATION IS AN IRREVERSIBLE MD FINAL PROCESS.
Cremabon I¢ carried out by placing the remains of ere de We and Me Audi holding the remains into a RMmdon chamber whet
Nay Xeaubjementolnknseheatand Aare. The heat and flame will lminOi and consume evaryMlryPauptbom and mall,
which am all Nat will be IM After tnmatlom
Follow,ng oemal the own atom will bear reasonable eBMs To menews all W Me rename and other matenal loco R4 r abOn
Member, but acme minimal dust eM residue will leery W at Whined. The¢amatory will mpenb InuoamHl one Megn mabfiBl Rom
the remains end Ma Inademal and bmgn mMdal tall tea dlapmo]of r WuiR by les. TM crmmetee remain¢vnll W meMmiulry
pulWeae] Irto smallpiecm and plattdImoetlai2nM]mnbiMrm um. Crematedmmnspananllyam"lpd unino
all fragment Is mucaniObb am Sk Ltlaw.
OonMNO OF THE CONTAINER
The aametery may only¢con the wmeinar harll no to i ncremMe human nmum in limited GmumMenm¢,such as confirm Me
itlBMyclMe remained onto ensure Mm no means a enclosed which might inryreerreployea¢trial Me mrowhypropeM_ N
human remains are delMld Ina conllmr which is not sul form ent such as uremonll or rental"aMr rile
ramabry W II regues Nat me remalm be moved lima suitable coMaber whey Nacupb Ma N aim. The thy ing of
cobaMerorthe transfer or removal of remains will W conducli camem wsnw and all W done in runway, with dignity and respect
IDENTIFICATION OFO
Name Of Orfmaxd: Eaton smpmn M lstatus: Total
Lam Known Adreas 157 John St Hudson Fan, NY 483E
Place of , 157 John St. Hudson Fete, NY 43R
sai OM OF Ass", DOS. 08-15-1938 Dab of Daam:W11.31320 Emimabevnprc 175
Deannpdon of®alrwwnbi W r in which remMe wiu be dowered.
Conugamd cremation container pine and Cardboard
PERSON IN DOOF DISPOSITION
(Fellmc ! galov lion, "nine ONE Or me INlOwmN
I MINJe are the ea¢ipnabd pare of me mAAa d daagnMd In a Hill a womnimWment executed Puremm b Pi
He taw Sel0201.
OR
al INJe hove no knowledge Nat the whemsed emwbd a wrM1bn instrument WbmM b Public HaWh taw Section 4201 ma
All Anal Anirediore be Me eaco¢i0on of his or her remalm and me are Va"=me)MAN pnomy under Public Health Law
Section 4201 and he"" Ni authiri cremation of"remains of He dxeaw]. WMur mWtomhlpb ths dacusal b m
fonow
Esther Simpson
DOS-189 f IRM. "i Page 1 03
Authorlutlon for Cremation and Dlapodrion
Nurnmer3 Me useespedu My 0uMNry 0M elhkn of We or ideal
NumMc_ Mealwal n. 0 yearto
1. A(rertm marginal in wrung purmam W Pu0lic Heath lw Samon@01(3(I
2. no survlNrg spaun
L. The wrvramp d=m eparter,
3. My wayourp card small were of We or older
A AsuMNn0 parent:
S. A trivial them aghtsen"am Men or spur
B. A lawally apaiaM gumiin',
F. Any wersil Whowen yeas M We or otlx mail as share in Nannual and wfioiyeor ticeM In nWlioMhip W the domW
IN A duly apWinted fiduciary of Me Mae:
r. A does MeM or nladva who has eseeuled a amen BfaRmenl punWM W Public HeeM Lew 3MMon AMi(]):
10. A met fimsl officer of a munnor a pure administrator appolaed pureuant to mal hurricane COUR Pmm]udAC:
1M. Any olMr person who re acting on behalf of may Measured and who has exewbd a woolen Badmen punuml W Public HUM
Law EectlOn a2011q.
G ALL THREE of Me lWowmv
i tgreby arm that Me baby of the demand does not roman a battery traflary pad. Power au, rMoac van ImpleM,
or radical Mania and Met any such Thermal were rembw] prior to the memories of MIS ANM1 Om Form. Fellun to sessions
Ness Items ptleras concedes may mount In harm to Ma cnmamry and crematory pareonmL
,519 IMR al Mrtlnrsouni have Peen Blur.to Kyle Kilmer
Me Ting Me removal of any penooal pr<MMw enter Miry ofvlus which my parson Miami ENw or any family tmmbr of Me
decial worm to pauses. Pine New Crematory
is not raponslbb brae numbed MprtmM Iamakom Me conformer form Me remains enrichments) Pamonal IbmsIMIn Ne
conhlrerorMM Ma remalnswill be Mea ed WNa cmna0on proun and cannot be a evade rcmmadon.
{t0B IlNe hereby auN des Plan Vlex CRMet
2 Wrw*rl W uemi They remains of Ma M "OW.
InPEOPTIONAL)
Had Mnby au%or a Me named Nnml direccor to prmW We delivery to and commission by an albmab
muel If named asscwury In We opinion MMe funeral dlMtor,and to amend Mi$bran to owners Me coact name ant
address of such 1I1&Ml cremal
FINAL DISPQ4RpN
They Person u om W anise They cremabd ameire MMe n oW M1oln 00 ve ter
Name: M S. KImer Formal Nana
Accord; 82 Broadway For EUx . NV 120128 Phoor 5161414[m
The cremM]remsiro M 0ga sell we dllnoed of as fWlowc
moral at aoee BL CBanebry
if Many ream do ma nai stow Men=Use pneealm aMamurelW amNmn.
Pine Uex CamaWry N auWrlsed to 910 p on of
emission
ion"no
e memory M.B. Kills Funal Name
M m oy nary
In pram or W rpiebred mad assassinations
C (IMY Oil pan
OOSl Patti
Authorization for Cremation and Disposition
(LAtl me WYwmv
464 AMU understand that if the mmaim arc not claimed v n lzo days of transfer,
Pine Nary Cmm=m M"dipaM M W Rdmism in
an lrrerxeram manna,,auch as by eMNnal won�n
CREMATION CO AINEWM
(ii ONE ortlre Mlovnrlp)
An um W W tal a e mnuire,rot men vemaYd mmNm Im Exn puMw]Man
and is desmdee as!Glen:
INrb Malawi mat 0 W um k had will m had me endm v Mm wain, anaddinift had anfairer day the used for dalrvaly.
OR-p�
1a_An um by mf yN puulMaM. IM1W uM.Irond that it no um is Nl W or olMnid predited
Pine View Commit will place the Oemegd maintain
m.daj
a red temporary container far mainly.
Tr.is Auehon'xap'en Ftrm Ms prdvi]ed b/ new Know was smut st
MB Kilmer Funeral Home PotiNa+avxnn
U Smal Y FM Edward. NY 126V
and isstret by me fair harder as w'Imeu to as execution ma
IAW IgK rKrmal a comment upy Of m'q ANhMssdow Foml.
TM pemi lW ed ESIow Ware Me payments)In control of disposaN.who by sig ning mis Autlwmew,Fttm.amm(s)
W Me eCcumry Nd containment W Me IMormstlon KornaiIn dals AUNarb m From and moment Ow lcmpoing.
Signed MY lam mym June ]g ]g .
shad �om
157 John M. Hudson FBAs. NY 12V9
wcan
Amid
thwarm alamen Mw� 11
K�1YIfXr88: I�Omlaw New, Mi call
Kinet
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