Lambert, Larry E. Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: _ R:GEIDV RETURN TIME: /F,
DATE S TIME REMAINS ARRIVED AT CREMATORY: W70 -;-"M 3060
NAME OF FUNERAL DIRECTOR OR REOR13TERED RESIDENT DELIVERING REMAINS:
fA4 01L-piSCq
NAME: lNgo I&I, YE r AS CE # I
TYPE OF CONTAINER: flI Utr41YIY affGca AoAmfl
PLACE OF DEATH: 16e p kl 46 II
ESTIMATED WEIGHT OF REMAINS 6 CONTAINE 'N WP
PLACED IN HOLD: t'IDp O rI
PLACED IN REFRIGERATION:/
DATE OF CREMATION: YIDITD /` y
TIME STARTED: '�'$1 -V TIME COMPLETED: ,Ay.,V� IM ((JJLL ^�
PLACED IN RETORT: II"NK—mOVEIX p II VP n!,I Q.'Ofn I ''�r"
RETORT # IN WHICH REMAINS WERE CREMATED: 1 FINAL
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE THE CREMATION LOG SHELL RE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
M1Sute
//////---------�--11111 DepanmentYof SMte
EWYORK Division of OIVISION OFhEMt3 Eoou5
STRE°F Cancl Washington A ass,
°"Myth" Cemeteries
Authorization for Cremation and Disposition
This AUMMUNon Form must W aomplN d and signed Prior Monry of remains Our crematlon.
Dare: 6j5jM Number'. 71 ,
Crmmtwy Nmme'. Pine Yew Omme um
Address Outlets-Road Queseraboury, NY 12800 Phone'. (518)705-9477
CREIMTION 19 AN IRREVERSIBLE AND FINAL PROCESS.
Churches lsWined art by placing Oe remains W to deceased and the designer holdig the remains iMa a Ge Om cbambxeMm
May are subjected to intense heel and flame.Than Mat and flame wi ll feel mnh and consume ever ing except bone and metal
Which am an that kill be left after Crvmauon.
Foil inmmason,Me comment vdn coke neutral efforts to remove all of the remains and other MMH21 tram Me Gemaeen
chamber, butsome minlmm dust and residue sell likely be left behind.The commonly will separate lncNemal and farm emotional Man
ally
pul"dZ into ssmall mad`a re baceLreMO s ems lgne ber mansfero as r CamStand lnma spnemely`mpvi"mv Mi noo
single siemens recegnuble as SMIl ltleeua. rum
OPENING OF THE CONTAINER
The co maWry meeymly open the continer holding the uncnmated human rumors in limited circumstances.WCh as idc M mMe
dent m
lry of the de can or a ensure than no material is enclosed which might injure empbyees or damage the cremaerypm"q.9
M1uman remains am MIMred In a container which is not suitable far cnmatlen such as ceremonial or mnul C22mt.We
resistant will rryulm that Me remains W moved Into a auNsble co l iner babe It apcepb Me remains.The cpening Ma
mnlalmr or the transfer or removal of rem91m will be Wndutled tekM a wltnems and w91 be done In privary,war dignity and reyeed.
IDENTIFICATION OF DECEASED
NameofDwbwmw'. Lan E Inmberl throughputs' Menlerl
test Known Mdrew: 1411 Route 9 Lot Fort Ed W NY 12820
Pl dDeath Gagents Falls HOSSFIft00 Panel Sl Glens Paris NY i ai �/mn
Sax'.[] MQF AgeJ B-3 DOE WDeath: DB tl ar
1936 Own of Dea Esilm md Wool:Fs_
Dolefu �on of mind in which remains
sssell be delivered.Jea / O ArD
PERSON IN CONTROL OF MSPoSITION
(Pors (s)in cmlolol diapwideM1, folds unit OF Me VkQm1W
I emNJe are the designated agent of too mentioned congealed in awlll dwnhen Inshumwr emceed parliament to Pudic
Made taw Sharon 4201.
OR
WJe hwe no knMedge that the dery SW executed a vmmn InNumeM pu chate to Public HBBM Law Reason 0201 or e
ca me-ing dietlbns for Me dlsposimn of his or her remains and IMg are the penanls) having wonder under Public Health taw
on<201 and have the right to authorpe cremation Of the emaine M Me deceased.NyWur relationship be Me deceased In as
follows
Larry E. lambeM1
rwmadwmeern
MS.180-f(Rev.08115) Paget d3
Authorization for Cremation and Disposition
(InaeR M1Om IM NstbeNxJ
Number'. 2 oe¢mprpn'. W
1. A person oeaignaled in smang WrBuant W PURAC Heats taco BetluMID1(3)
3. Tom surviving apouaei
L. TM surviving domeal parter'.
a. Any¢umbing mild eighteen years of age or come.
A Asummng parent;
B. A survived sibling aigreent yearn of age or doer.
B. Abell appamled guardian'.
7. Any Mrsonlsj eighteen years W age or older Mllrled to sham In Me estate and vi Were dowel In admionenip to the dewaMdi
8. A duly appointed fo ry ucin of the estatei
9. A dose friend or romwe who far ew Wk a Oil stebmem Pursuant ro Pudic Health Law Section 4001 O11
10. Aohief hswl proper of a et or a public aft imseal appointed Wrmanl A the Sunogala'a CouR Pry UM Acl',
1W. Any other person who is strong on behalf M Me dew Wed and wTO has emared a wrial statement pursuant W Pubbe Health
Law BMion 421.
(dead REE&MB/NMwng)
MotenmBbyaMrm MMMe body oft"denwaeed does not contain a bal battery real power cell.rail ove implant.
lowgve denary and that any Sul modelwere removed prior W the execution of this AUModzetion Foml. Fallurelo nmow
boost Ibme prior cnmetlan may result In hamr W the cmme"and cremeWry pnsonnsl.
More affirm that employers bare been Four o oarleem Furenwem, hipere. Ini
al the rem¢ lof any personal pmpvly or Other Ming a value wTill any peen signing below or any family member Of Me
dewa¢BdMaMs lopreaerve. Pine uieW Cremabflum
is not mapensible for one removal of pamnal Mnu from Me wrath w from the remains of Me d aw .Personal lams lad In Me
wnYsxr Or whom the remtlm will ba desboted"a cR aUon perms and cannot Its reMeved sM1er cr Won.
•hereby authorlze Pine V�CremmaMdum
to aM Me remains of Me domua
FINAL DISPOSITION
Te�fu(lp ea Wrewiw Me mmeled remama cl Me deeased M1dm lhry PemaWry i9'_
r
Address'. $ *'i l RB 1,1 Phoni -;tI V Z43
The cremated remains M deceased Wil be deposed of as fdicam
V 'uh, S `
If for any reason the pryxn namsd some does net lathe Possession of MB oemated remain¢.
Pine View Crematorium oauM and togNePw eul of
merenumaWCill Fu He I byddivery
In perwn or by registered meil. nrywre»wry
LaM E. Laml»rt
T�
DO!ii(Full OWIM Page 2M3
Authorization for Cremation and Disposition
poim me a)
f understand that it Me remains are not claimed whin 120 days ofuenadmin
Pine View Crematorium may dlsprse ofMerenalnil in
an immovable manner aom ea ey a shanne.
CREMATION CONTAINERPURN
meta 0 eeE r�95wing
_An um to We used as a Conner am We aemaled resins has bean putllaeed M1pn
antladescdhmasbiloas.
IV am uundays'stand that Nthe um is We small Mtl the entire cremated Camara.an additional hold Container may be Used far dabrarry_
umi is me or wmmosed same unnentand tat f no um is purchaii or Mherwtae prommad
Pine Vim CremelOriUm will place the cremated rename in
a raid hmpo2ry container Mr delivery.
The AUMo aUO Farm was pmoNed by Cement Funera HDme, Inc me executed at
Carleton Funeral Home, Inc
68 Main St., P. O. Box fi] Hudson Falls, NY 12839
and is signed by thefuneral director as wlNess to Its emMion.
IAm haw mce coo a compiled copy or this Aulhotlaa0an Form.
The Monsanto) identified haiow heard the paeonfa)In caMol of dleprshon,who by Signed;NW AUMw SOM Wpm,at S)
W Me securecy and cmmpieYnew of We Information contained In this AUMotlze Form and 8u dze(B)Me foregoing.
signed MisN eayof .tune 2D 20
Joan Lambert >r'
1411 Route9 Let] Fart EdwaN NY 12820
ans"i Seem,
WITNESS: G�
Carleton Funera Home, Inc. 44WWM.s klLl11�
I�m'�T�aMRdK�
9A
Larry E Lambert
D�18964 gam Gi Team 3 of 3