Kessler, John Jacob Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: SS f RETURN TIME:
DATE 8 TIME REMAINS ARRIVED AT CREMATORY: waIZO II. 10M
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
satAII MID
NAME: _ ��Na r.Uky CASE %(_
TYPE OF CONTAINER: IMIIIn.P � - I LP� MfI `
1�� I .11 n 1� 1.(E r�q1
PLACE OF DEATH: IS8 BMP WM Q/i, 4,11 a& IN1V L- (�
ESTIMATED WEIGHT OF REMAINS 6 CONTAINER IZD f#
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION: Wnne 6n
TIME STARTED: I,M pn TIME COMPLETED: 166 1I/
PLACED IN RETORT: I ib Qp MOVED: Pool
RETORT # IN WHICH REMAINS WERE CREMATED: ?w %yir _ 1, ' '�•1'' /1
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE:THE Cn[MSTION LOG SHALL BE RETAINED IN THE FERNMENT FILE OF mE CREMATOar.
///��� IawyeaMm
�J NEWYi Division of
nnTPOF DIVISION OF CEMEfEFor.
OPPoR1VNnY. Cemeteries esMngtm Avenue
lAffiary.NY 122g(000I
Telep m(SIB)4w-e226
Authchril for Crematlon and Disposition
This nmhonaaumr Form must be Cemplered and flamed peer to delivery of remains for or,mMl,,.
wte: 0611&2020 Number. 71�
chemistry Name:Pine M" Groin Wdum
Addrese:51 Quaker Road Queensbury NY 12804 Mrwx: (518174544Tr
CRE"MN 19 AN IRRIWERSIll AND R UL PROCEA.
<:rxnaWn is ra wt M Placing the MMina of Me dery and the monarch hoMFO the remaim Into a mma0m chamber Man
Nay,ere subjected by Intense heat and same. They Met and None Mll Incl state mmumea ing except bone and metal.
Mich am all Mal AIR be loft Ater cremmon.
Follwin0 chairman, Me uemamry All take mergers efforts 10 mmove all ofMe remains and other material M1om the uenadan
chamber, bN acme minimal dust and Mal will likely the IM ben". The memory MlI separate imidentel eM foreign matane hcm
Me rimainsimsidenodentalam foreign mabnal MllMtliBFme]Nae rpwhetl bylaw TMGmatedmmeine Mllben LanMlly
PuN H 'rmtsmall Pi $ate PkmdiMadmgnatetlwnleimrorum. QemaNdmmimgenmilysm WMNekunNlM
Nrgx fragrwnt is recapnMOle as soadmal N m
OPENING OF THE COMAINER
The earnestly may only down Me ctmeintr holding m an pma human remains mlimited Grwmatan¢s,gich ab to wnfirm the
IdeniTy othe M-w onto ensure Mat nor mmenel is endows which might injure employee,ordama8e the summary,Smpmry N
human Amains,am delivered Ina camalmr Mich Is not ubbk for cmme such as ceremonial or rental casks,Nw
whematory will mtulm MN the remalm M momdmo I 6 suMble conblmr Mom HaccapN Ne mmelm. TM opening W e
ntamer or IM burger or removal of r Mwin the conducted thed"a Mmw ere MuM done in geay, wMr dandyand wali
IDENTIFWA�OF DECEASED
Name of Deceamd: John Jamb Kessler MarYl smbw: Married
Lag Known Addmw:66 Kettles Way. Queensbury, NY 128(4
plain of waM;Home WThe Good Shepard. 198 Bluebird Road, South Glens Falk, NY 12803
sex: ®M OF roe: 83 DOB: OM1119M mmMOeaM: 0W17M0W a Nmatedweght: )C l4D
w,CmatsincfgskNM*n1mnwr M whim hem:na MuM daliwa .
Flberis ardlaltemasive contain adhieRh was Company
PERSON x
(Porxw�xnhd o/Naneslfron, l " Q4EMtlm fiko' wirp)
1 emNie are Ne designated agent of Me� deagre In a MII or borrowers amsuled payment to Public
IMII law8emOn 4201,
-0E-
IhNe have no knowledge Mat the declassed executed a Mden Inetmment our,uant to Public HNXh Law Setlim 4201 ere
Still fining direction,for the dispmidm M he or her hemems and PAIRS am Me peraanss)having marry under Pablo ful Law
8ecMn 4201 and mine the right to 8tlww vemamn of Me remains of the tle¢amd. Mygw relationship to they Mon ism
Alntm.
John Jacob Kessler
DOBAegBHN (Rev. 041 Page l af3
Authorin lon for Cremation and Disposition
(InsertM1 fMft90 bw)
Numar: N2 Cescnptlon:Surviving spause
I rscnd signated in among punueMro part Heats ea Lase Selo,, A2o1(3);
Ap having sp ruse;
2a The mMving combine peMer,
a. My surviving chile eighteen years W age or order
A A surdeirq parer,
S. A surviving sibling eighteen reon W age or olear;
S. A lawfully agwiMee guardian;
a. AEUPmppofiaMei eighteen
fitlmky Mt the aage
or older entitled to share In Me ca M arere ste,and veto closest in refatmahip i b the deceased;
e. A dose Meth or relative who has combat a whXen mossmeM armor In Public HwXh Lee Serum 4301(7);
10. Ashm mucal officer ma county"a public admiMstrsta appainkd pursuant to the Surrogate a Court Pmxdun PCS
10a. Any other person vino is acting on beast of the e6wa¢M ON who has executed a iammm shipment PWMW b Public HeeM
fig Sander,4201(71
hi ALL THREE dare la4onwg)
k Vista hereby eRrm that the body W Me observed does nMcommin a battery,Caney pad, poaxr bill. radgagiva national
a neip%tlrodevae uN Mat arty swA materiak axre remm'el pnortrlM 0eea1'ronWNi¢AUMorintlon Ferro. Pailumbnrmve
Meant Parker W momentum rosy speak In harm b the ennrebry and mandatory" amel.
y. i uwe mean Mat instructions have bean given ta Stuart A,Philo
regarding the nnmei W SW peremal property or Other MYq dvalm much any perecn egnkg babe orally remlN member dtln
bbiasm weave¢to PMWe , Pine View Crematorium
is not responeibb tar the removN W pcaorel Inns M1om Me coWellar On man the remew W M demand. personal therms lea In the
container or area the ream wnl ber drkoyad by the cremnenon process and cannot bar nbNvad agar mnmstion.
d R'K W$hmubywnnrW Pine Mew Crematorium
�i
mmrarumdq rpneNn Wise tleceaM.
thadewOPTIONAy
IMw n.nny amnadae Me nameem 1 .b PrpmaO rod eanv.y to and cremation by an alternate
Cmemebry, n demn" necessary mtln opmtond NnePat elrecwr,and to amend this form to provide the correct name wall
Address cesuch Warner their
FINAL DiSPOB TpX
Tce Iarsan.vthadme n mm�a are amala mneim a the seams xwn dw vemaary is
Name'.Singleton Sullivan Potter Funeral Home, Sarah A. Philo
Addreas: 407 Bay Road, Queensbury, NY 12804 Phone. (518) 791
Tina raledlomamaNw ceelwoeedWrblMn:
To be etuetl to the temlyily,
nra.nr reepongn mlwn mm.d.baneoes nor nee woman W Meaend.w ramelm.
Pine Mew Crematmi aa.Xlwllzedrogln Pa0e0eeianW
Meremelmm Singleton Sullivan Potter Funeral Horne by deltmy
In ninon a by small maps John Jamb Kessler
W fyigerv. 0IlN) pall 09
Authorization for Cremation antl Disposition
mare bvrwrny
k LWr UMenWE Mar doe remains are had cWmM Whin 120 Uaye,of oem.rbn,
Pine View Crematorium may dispose of the owners he
an theorematic manmr. sum as by sranennp. awevwem
CiMEN ON CORTAMEflNRR
fIbbMONE&ft so,aowbpf
Singleton Sullivan Patter
Anumb be uun Be a DMbinerbr MB tlemeleO routine ri Geen pv N caeE Morec .. wmv-
ow IsatlUiEM asldlum:
War Moderated Mar HIM um 'c bs angel b We Im Mtlro amended menalna an additional nap conrahler may be used bar dismay.
Jy—M um Is ml}aapuMefeE. IAVa uedeMao MNMm an u purcbeaW a orMrwiee pmNded
Pine View (Cramabllum Wll piston the amended! remains In
me" I'm i
a rgN deem ormry container for delivery.
This Aua Hz on Form was provided by Sarah A. Ishilo wee eMBCNMM
S irglaton Sullivan Popor Funeral Horne
e.wa �ww
407 fey Road, Quee *Io ry, NY 12804
eo is sidnrd by Me wn.21 Minimum as wMeea to as mom on.�aw.0
Ways have resrvM a compared may of this AUNorizeaon Form.
The penon(s)IGn11Md bNax Indent the penords)in control adspwplon,wed by slaving this vers Wbot Form,Whi
to are accuracy and sheepishness or Me IMo Van ponbimd in Mb Aulharherwr Fomr and aaMoream)tM brpdng.
Slaved this 18m day os June p 20
Barbera E. Kessler &rim . E
88 KeWes Way, Quesmil , NY 128 1
2�
n..eo ... r•
WITNESS: o
Sarah A. Pbilo
n..vamav*rw e'mwrw ,1Q�eaatlpr.e-
12869
John Jamb Kessler
Nrww�a
00s1896lIRev. 00.R0) pargi