Kendrick, Brian Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: 6Aftj RETURN TIME: p.
DATES TIME REMAINS ARRIVED AT CREMATORY: 4IS IrE T'IrfD
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
SrRE2 9Aga2 _
NAME: J"WJ ew/y�mfV // ^^ II CASES 7Z4
TYPE OF CONTMMER: LOIria aM�ULIP Me' siwr .y Me✓s)M 3tSPg
PUCE OF DEATH: 44 r rul EI Plhl II
ESTIMATED WEIGHT OF REMAINS & CONTAINER—/� 7W MF �tn'(6 r
PLACED IN HOLD: ZnEA
PLACED IN REFRIGERATION:DATE OF CREMATION: W101to 01..
TIME STARTED: AIrAII TIME COMPLETED: a;gff I/yph
PLACED IN RETORT: IDS M MOVED: p,��' q :
RETORT P IN WHICH REMAINS WERE CREMATED: Syyy .`?Al( —
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN " HOURS
FROM TIME OF ACCEPTED DELIVERY: _
NOTE THE CREMATION LOC WALL HE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
a Authorization for Cremation and Disposition mse.,.nma.Iwz,.Ia
o.cem wwR..,°Maaw:d ep:2o,
ly a
Tireaudrnriae Ferro mnx he conplesetlandal WpNO dtllVMyorramaMa(w cremaaon..mx
Data: Wi lw Numlaer
Cmmffiory Name: Pne View Crematory
Adtlress_ Quaker Road, oucensbury. New York 12800
_ Ptlosle' 518171S44
CREMATION IS AN IRREVER ISM AND EINAL PROCESS,
Cremation is carded out by placing the remains of the decieseel and the container holding the remains Into a
wemationchamberwheretheyaresubleded to intense heat andflame.Two w and heat and game ill lMne H candidate
mNng eQapt bmle and meal,which are Al that wan be talk after eemarlm.
Following ore mation, the cue money w in take me so no b In axons to remove a,of the remains and other material om the
orientation dumber, but some minimal dust and residue will EFely,be left behind. The crematory wIn isolated mmartal and
foreign lot eral room the remains and the Incidental and foreign material will be disposed of as required by law.The
cremated remains will be mechanically pulverized into small Peces,and placed into a designated container Or urn. C.IMWed
ressains;generally are pulvM uMn nt dryle frapneM Is remgnizaae as skeletal time.
OPENING OF CONTAINER
The crematory may only open the container holding The un-cremated human remains in hmked circumstances,Such as to
confirm the idennly of the drive ased or ensure that no material is enclosed which might iryure employees or damage
awryproperty. ifhwanemalmaredeliveredinawntanerwhichisnot WMblebraema s maceremmnlw
rental papard,the cremmwy will require dut the remains be moved into a suitable container before it locales Ru a inc The
opening of a container or the transfer ortemoval of remains will he ,,du,ted before a witness and will be Moves Mirwryy
with dlgnity and respect.
IDENTIFICATION OF DECEASED �aS�
Nemeofleceesd: V Aa Ck Mariml Stoma: y�
Les< Nnnwn rwd(rease. 27 U AIcEacd Div , Q"
Cd
Place of Oeam: "f v
Sed0KA OF Al L Oda szl*q, Enlmaredwaiaht. 2001bi
Desvipdon Of askeywntaiw in yAkM1 remains will be delivered:Cultural Cardboard! Box wafth PMye od aRR
PERSONINWMAOLOFOtWOSITON
(pere0 s) in mnbdl ofdisposdlon, Initial ONE of me following)
_I am/We are me deslgmted agent Of me dereased designated In a will Or written Instrument Accused pursuant t0 Public
Realm lawmcion Q03.
-OR-
f`k� I/We have M knowledge that the demseseC eaeclsted a written in[Vurrent pursuant to public health any sttdon 020T Or
a will wntalning dlrectioM for the disposition of his or her remalns and)<Ondnukd near "eel
0. v_ A k
orsn.wr,uw.wnn awnaamw walla
I andsw are the spends)having Priority under Public Health law amlion 4201 and have the ngbt to autbmze cremation
that remains of the deceased.RAY/Our relationship to me deceased is as fmmw::
pnserz/mm the lose bebw)
NumbetMLDeecnprom WI-1-p
A person designated in ending pursuant 0 Public Haugh Lax section 4201 (3),
2 The surviving spouse',
ga. The survNing dom odic padrrtr,
3. Any surviving Child eighteen years of age or older;
4. Asurviving parent,
S. A surviving cabling eighteen years Of age or cider,
G. A lawfully appointed guardian,
7. Any persons( eighteen years of age or older entitled to share in the estate and who came aosea in
relationship to the deceased
U. Adutyappointedfiduciaryof Neestae;
9. AdOi hieod or reladvewho has execoded a embed statement moment to Public Heats tsw§4po1p);
10. A ci fiscal offset Of a county or a public administrator appointed pursuant to the Sunogate's Coud
Procedure Act;
100.Any Other person who Is ecginy on Older of the dttpased and who des executed a wrillen ycontain pursuant
to Puck Health taw§4201(]).
IiOggLALL THPFe of Mefeem gf
Pifik I/VJe hereby affirm that the Mtly 0 the deceased does me contain a battery, battery park. slower set radioactive
f Olanq or radios five device and that any such materials were ttmOved Prior oche execution of this Authoriaadon orm.
Fanure to tense tAese Items pr;g to venation maY rewh M harm m lM[remMory sn4 vemerory pewonnel.
I/We hereby affirm that Instructions have been given to sVfxx&nrbmmel_S egardingthe
minimal Of any personal property Or other thing Of value which any person signing twice or any family memi er of deemed
violas to taxi bawmy.m,el I+ aV'
is Pot Items from He,functions or from the remains Of the dtteazed hrsmwl items haft M the[ontainer;or were
the
emarmin wiill he
d[witurnn1ead Inthe ntmaten process and mme he sawwwwa new Omovi
A-- "A"hereby aumWR(may l Pine View Crematory m[re WMam of
ifdemared.
FINAL Digeoperadi
The person auchad iWreserve flux aemaed Hemline of the bernased mom to crematoryf0
Name:
BakerFmmull-ol Personnel
Address' t1 �5m Phase: 518 ]81-0303
The pematai Moscow W deceased will be d;sµ dWOs become,
nelmn mfam;y 0 bedewed
If be any comou the Ignmn named above does ml rave possession of Me[remmdOd remems.
roemales L—p is wdddbmi to greepsae>sbn of Me remains0
r^"•'a"'k^'^I by delFrery in person or b/spread marl.
e0.Ywa�IOn.amb fty-i tlts i/ upd6i —NI,aafs
I L IrPm undetamnd ma 0 the remains are not cleimeU within 120 days a cremation,
mx) Pine V' f
such ins by srahenng a may dispose 0Me remark In an inetrierepp manner,
CREMATION O T IN
LRIdthONE of thefoNowin)
An urn b Ee used as a container Mr the imitated remains has seen purchased horn Baker
Fu—Pun
Hama and Is described as format'
ii ModerstaM mat If me um Is too smap m hold Me scene cremated remits, an additional rigid mummer may be used
for delivery.
OR-
f<LAn um has not yet been purchases, IM1Ne underspN tat it no um is purchased or o"mme provides mw as,
°""I Pays View paccurbary will pace the crenraed rernains m a ngid temporary
container fir delivery.
This Authorization Farm was provided by pimewaamvmmi UsaPaN¢Mp141pJ
was executed at wxwhww
u""°'^'"""°aw^wi tt aM in agnad by me knew director
as witness m its execution.
Ii have reseived a completed baby of mis Aumwvah n Form.
The persons)R enGfied belay tafare dal persons) in conbdl Of lisposition, who by Wrung Mrs Aotgnzalion
FaFm, afferi bMe Mrsi and romplmleness ofMain/ormetbn wmal Nis Aulhomwilko Fwm and
authaim(s) me foregoLrg
sleoea thl W—W—
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