Nolan, Mark Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: RA I'TAMEL RETURN TIME:
DATE 6 TIME REMAINS ARRIVED AT CREMATORY: NIIIUI Ioeaft
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
K4//F . _ KLIAMw,
NAME: 1wgR roolga C49EIR 70
TYPE OF CONTAINER: AM
PLACE OF DEATH: tRSPI{`I
ESTIMATED WEIGHT OF REMAINS 6 CONTAINER IA1 I�
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION: TO
TIME STARTED: to Ad TIME COMPLETED: 24PVA
PLACED IN RETORT: I0:9 ^ MOVED: IML 7O (YYI R/Dm
RETORT # IN WHICH REMAINS WERE CREMATED: Pa+ Ir1V'
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 4S HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOT&THE CREMATION LOG SHALL 9E RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
oATEOFOFOmK DIVISIOfI Of olvolox OFce.I,'I'll
Cemeteries en •nnaAll of� ,
close, comr4smi
aaawrem
Authorization for Cremation and Disposition
"is AuTwl on Form Meet the aomplebtl antl gignW prlorke SMMi of ramalnSMCm 090n.
Om_Jule 9.2030 Numner. W3
Chanel Name.Piro Vas Cre Mry
Address.. 21 Dome ROW, OuasMWm No 1281 Pflp,y. 51&74644W
CREMATION 19 AN IRREVERSIBLE AND FINAL PROCESS.
Cremation Is mmaE am by plating the remains Mine OemasM and Me Will ho dirgtlm mmalm Into a cremation chamber wherel
May are su0lecked toInhme neat and flame. The hot and name will lnclnamm and comume everything exu Wine and meta ,
wMchareanulatwill0aleftofWrrnmwon.
Following uematicn the crematory will take rea$OM 6elbrbb remote all of the remains and other matenal Rmm Ins cremation
clamber.ONsome minimal dust and residue will likely or let tagund The century MII separueiommnl and faegn moral from
the remains and tM Incidental and breign mebMl MII be dispaced stay reouiied by law.
i Te cremated r ema in MMn'oly
protocons small pems and plem Ins a desgnaked mMmo,orum CmmaWmmalneWnerallyaMpu single fnanrmt Is rscoanlvble as l l Nuue.
OPENING OF ME CONTAINER
The crematory may only open Me co Amer hotliy tna uncrematW human remaina'm limited umums rkes, such as toconfirm the
identity of the AMeeW or to ensure mM no matenal'is enclosed which might must employees or damage they crematory property, if
human KmalM ary dNlwnd In a mMtlner which Is ul subbble for cr aYon own as woo ltl or small most,rue
mOWry wills In OW Ns remains bs maoM Into a Whathe container bbn tt accepts No romtlns. Theopeningola
mintameorrue transferor removal of remems wil M conducted before embassy and will lea done In wool vnm dignity ant reaper.
IDENTIFICATION OF OECF ED
Name of removed. Mat Wan Mental5lo" News MMW
Last Known Address'. 21 Jury St Am 9D.Glans Falb, Nv 12MI
Place MDeath Glens rails Hospital, 100 Pat StttaL Glans Fub, W 12So1
sa.'. De M ❑ P Age. 67 Doe. 5/5/1953 w ON :wmn EAMS MN K 180
Oesmputln of nskWwMow in Mr NmrWwwill be OearelM.
Minimum Cremation Casket, Florence Casket CO. Candonar8/Pine
PERSON IN CONMM OF DISPOSITION
1permNxJMconhclo/WryMgm, {)GONE NMa RWowirg)
I amMR ere Na tlwigrarld agent of OR dma dmNnu In a wit or Argon instrument mxx WrsuM WPubXt
N M for C ion 0201.
-OR-
Asks
holy W knowledge that Medeme esmWd a wgen instrument punuot to Public Health Lw Section 0201 or
wit wining mmory Iine d'mp don of his or Far remains and of am flay par (p having Gritty Under Public Had tin Law
is5:n 02o1 ens have MergMtoautlwllxe oema4m of Ne emans alNadwiase]. *10urrelatloMMpWNadec 5WNu
ftli n
Mark Nolan
OOS188Sf(car, oal Page t of 3
Authorization for Cremation and Disposition
onwn Mel,e a w)
Nunbrs NsOip4M: A sumving sibling e9nteen more cops mauler
1. Apersm neaNnatetl In swung pu9uam W Publc Health Law section 4201(3)1
3. The surviving amuse,
2n. The sul common Partner',
3. Prey surviving child eighteen"am of age m Oodar
4. AsumNng parent
fi. AsuMvmg sblung eighteen Ram N age or older;
0. A lawNlly appOli guardianl
T. Any contents)eighteen Perry Of age or older erNikN to share in Me estate are who l Ware clMesl In Meuonanlp to Me damesed
0. A duly appointed(adieu lNot mtak;
S. Atlm frets or reliance who has amcuted a winner statemml sumuant to Public Heats Law Section 411
10. AM4f fiBWI Oemr Of a county wa public administrator massented pumuaol to the Sunnis Court Procedure Artl
ran. AM other pa9M who is ectirg on behalf Of Me tlawaeM and wits Me welcome awrillen statement pursuant to Public Health
Law w4201(m
Ta- �gu�ld A/EL�maxi of the Ahlowmg)
I Ma hrtSy affirm Met Me body of the Drexel owls cot mnteuu a battery, battery"a power pull,redgectiW"ant
Or radloacuvedevar and that any such maNrlels;"m remained prior to the formal of Mb ArMonntlm Form Fauuretoremove
\heals Ibms Metal emmapon may rxult In hand to the cremaory and anmatwy p nmrP1.
May An that Instructions have Oman man to Megan WUW
regaNing Me renoval Wany personal pmwM1y or other thing W value whal any Anon washing bNGx of an family menbm of to
bewated wishes to premium Pine Vlaw Comm al
m..wwwrn
Is not resconsl0le Sir Me removal of personal uncommon to mMeinercr M1wn the remains of Me tleweb6 PMOnaltmMlMinlhe
container or MM Me remains will be deeaoyed by Me crnnadw pm;l and wnnM be rMasad after common.
Me hem"royal Pure View Crematory
W cmman the anomalies of the dewaead.
(kt alOPT10NAll
Wn herby meffi a the named lunenl dlMmr W pmslJe M delivery W and cometlon by an aMmab
cmM;tom, If deemed necessary In to opinion of the fumnl dlneWb and W amend this form to provllN Me comet mean and
addnw of such aIMmnl crematory.
FINAL DISPOSITION
The moon control W rewlve Me cMmabd remains Of Me demands ham Me 4amalory is
Name. M.S.berner Funeral Name
Address: 123 Nunn SpeaL Asian NY 12M Pie, 6188384 18
This uetrwkd remans of dewa/I will be innocent of as bpcm:
pkW IIlCII.e4
nfmanv reawn tiro harem named. awe not%l , onofNevemaW arcs.
Plnev Cronatcry is wMmuxed W gray m99ession of
concern,
Me mmaimW M.S. Kamer Fwlerel Ncma � bytleliwry
mw
tin "men or by regenred maul. m� Man Na4n
OOSt808I tgev. ON20) w.i. Ppe 2 of
Authoriution for Cremation and Disposition
(ittleff me rarorwny
�=gjl Wil i ndoul and that it me rema ins are not aaimed wlmm 120 cans or uwnel
PlMvmcmmemry may d@µN of may remains In
an,m ab4 manner,suT Me by suibnno. d[ n
GREMATK)NCONTNNERMRR
w gM ONE of Me bPowal
M um to be used as a common No the dema id mmalm him ban pumhymd from
and is deserted Me follows
IMb understand taut it ine um is coo small by hole W Mom memo rem aim.an aeelbonal reel anoter may be used for delimy.
`-O�R-./'.'��
t Mwn lanotyntpumKSOc. Valle imemmnc that itno urn is purchased or mhmtiae pmvleed
Pith Mary comedy vnll plow the assured remama in
a near temaarary common for delivery. w�f[mmanrh
Tham AUMomica n Form was prul by MapanYicas was weachrfn
A.B. Kilmer real Nora wnm.wl
123 Mom Striel Ahgyle. NY 13009 F�mxmwN
and Is signer by to Moral dlracw as wiareu W N 6rtssual
WJe have mmrvet a communist copy of this Authorization Form.
The pwaur(s) IdengM blow Isla No the pamnts) In conl W clspalNon,who by sign Ing this AUMotlaeWn Formal gs)
to the accuracy and complabnms off that InMm Wn mnhlmc N NIs AuulMoahetbn Form and additional the foregoing.
Signed GMl. Ing der of dnnn 30 20 T Mary Grah
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323 Chamm Road,Gmerravel NY 1203! s�
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WITNESS:
Morgan Was
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Mend Malin
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