Doyle, Roger Pine View Cemetery 8 Crematorium
Quaker Road
Queensburyl NV 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: ME C IN D RETURN TIME:
DATE B TIME REMAINS ARRIVED AT CREMATORY: bIRIW 9 IrtAf1
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
YMeLI HOEEHJJ
NAME: Kgu RtE (L CASER �50
Yiy TYPE OF CONTAINER: W 1! 1NeADMvQ
PLACE OF DEATH: R tTaac PE, ARVIV AGE L&AIr ki R'*
ESTIMATED WEIGHT OF REMAINS A CONTAINEq M IL, ADS IEF
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION: GIZZ IRA
p
TIME STARTED: I-I{DAI•I TIME COMPLETED: bp6yr�I1
PLACED IN RETORT: Ww AA MOVED: n-•� I1 1 it.'^'fl l ) Q:�
�'1 • 1
RETORT q IN WHICH REMAINS WERE CREMATED: SIyHx *gLRN[
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE:THE CREMATION LOG SHALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
State
'D.p.m.maw s
"NEW PORK Division of DNISIONOPDEMEIERMS
ST
SITAl """'" Cemeteries Dn"'mme,uPl"e
NYa23;aog;
resume,Areas.NY
mil Wv
Authorization for Cremation and Disposition
This aurXoatral Form must be completed and Will prNr to silicon of remains for cremation.
Dao:06151P020 Numhar: '75'0
OremMry Names'.Pipe V'ww CMm
Mdreu:Quaker Rd, Ouwmbury, NY Phone 518-745Y77
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Crema tit is Camel out by peeping Na remains o1 Me de�'aa jd and the wnfaiher holding fie remains Into a suburbn chamber whore
they are subjected to arrested heat and flame. Tn hive and Rama AM Incimm area consume ekftgdkp aanin Win a"mMY.
which am all that will AS Inc spur cremation.
Followed oriental the crematory will take reasonable aflons to remove all of the remains and other maeriel how the cramdllm
Mambee but some minimal dust and residue will likely be left budnd. The crematory will separate mddental and foreign materiel horn
the remains and Me 'mcidemal and foreign halal will as di$p grew Meant bylaw iha oemated remaiiu vnll be meduniully
purvemed into smell paces and placed Into a designated coMameror um. Cm=W remains generally are pulwd until no
Single hagmant is racegnimble AS insisted Mrsam
OPENING OF THE CONTAINER
The mandatory may only open Me container holding the uncrerealed human remains In limited rLamslancea such as tr¢nhnn the
kamity of Me dermaed or to ensure Met no medal is welczed which might Injure employees or damage the natural pmlmrty, R
human Met am Midwest In a computer which Is not suitable for cmnation such as concentrated or rented aeka4 the
mnatuy will ncgum Met the remains be moved Into a SoMble mo finer bebnc it Me remains. The opening of
trMainet or the transfer or emoval ofremalre will be conducted befog a wbney and will be time in privacy, wM dignity all msrem.
IDENnRF TON OF DECEASED
Name of Omani Roger Dgle All Sous:chained
last Known Awress:12 Calls Dr.South Gore Fells, NY 12M
Piece of Death:12 Come Dr. South Glens FYs, NY 12
Ss: OM [IF Ap.:80 DOD:05104"940 Data of DWM:olLlarzO2a Fsb dweght: 150
Deal of raskeu¢noin«in Which remains will be delivered.
'- ' - (nntainer ping jrpW
PERSON IN CONTROL OF MSPOSITN)N
(AnswerIn rondo or asspmint 'ndler ONE As Me structural
emNYe are the Musical agent of the des awd dealgnated in a wgl or wMlen irebumant thave ] pupart to Public
pealth taw SMIM 4201,
ling
haw no knowledge Met Me de®ased executed a warren Takeoverspursuant to Puma Health Lew Section 4201 or
It rya taming diRC4Wa for the diepcehion of his or per remains and than am Me pe90n(s)having peachy under Public Nwnn Law
Season 4201 and have IYre right m authome cematon of Me remains Once depeaaad. My/Our relationship o the dewaew la AS
follows:
Roger Doyle
DOSTI 6f Mav 04I23) Page 1 of 3
Authorization for Cremation and Disposition
fIMIbIfM Mrolwnpl
hNWaunWrsMMtlnt Iranremindare Mdmi x in13ona"oforemation
Pine View Crematory may disuses of the mmains in
wa nw tl
an IneMBvable manrwr, eucM1 as bycattenrp.
CREMATION CMTMNEMRN
TFAn u
of Pm to e( Mc us to oe used az a convener he was ttemalM rpnalm has Mean purchased Rmn M. B. Kerner F m un 'lnH�one
and mdwcnbeaasfol M — " ,/
Me unEerabntl that if the um s too emaY to M1ON Me were verrolM rennine,an WJpional rqH container may Me usetl Mtldlvery.
pR
um is not yet puNYsetl. WVe understand that OF no um is Purchasing or 1MN provided
Plre Yew Gnmskry wll place has cremate remains in
m..eo..ra
e Him temporary mrMinerM deMvery,
This Authentication Farm was poviMi by nunnyNy Murphy was esewtM T
M9. KIImer Funeral Home mvrem
?«wewrerura
138 Mein St South Glens Falls, NY II803
all in sgnad by the Nname director as v.Mess to Its announce.
IMIe have received a completed copy of Nis AUMwlaa ion Farm.
The passing) Identified bases Isbn Ms psrsonls)in mMml of disputation,who by signing NIs Autlwtl»tlon Form, Mbsgs)
to Ms accuracy and completeness of MsIMmmNloncontained In this AushorhaOon Form and au arise(s)sill foregoing.
Signed gas 15th day of June p20
Oiara Gayie ���
tat Quad Drive Scull Glow Falls. New YoM 12803
Akice
Twoammwv apere
Wearym
TimolM1y Mr
urphy
12587
pager Do 8
ae..asm
DOS-1898JtRav_Opli Pegs 3 of
Pine View Cemetery and Crematorium
21 Quaker Road
Queensbury, NY 12804
Authorization to Separate Cremated Remains
Funeral Home M.B. Kilmer Funeral Home 136 Main Sneer SOF, NY
Director Timothy Mumhv
Date Juna 15, 2020 Tag No. 7 S0
Uwe authorize the separation of the cremated remains of Rover Doyle
Uwe further agree to hold harmless, indemnify and defend the herein named crematorium as well
as their representatives, from and against all claims, liabilities or damages whatsoever which
may result from this authorization.
Signature
Gavazou Operator
a 2015
Authorization for Cremation and Disposition
Number
2 Meu9fnerow)
Number 2 Description: The aarvlvlrg apahne
1. Apereon designated in weing pursuant to Public Heann Law Sodon 4201W1;
z Tom survmirg spouse:
U. The surviving dwreatic partner
3. Any suMNrg child eighteen years M age or drion
a. Asumvntg cannot,
S. A survmmq sibling eighteen years of age or older
6. A lawfully appointed guar man;
L My dersomst eighteen "am of age or alder emitted to Mare in Me oft and who iNare Gosesl in reletionalum to the deceased:
S. A duty appoin and fiducary of Me me me,
B. A close trend or remfice who has executed a written statement pursuant to Public Hart Law Semon 4201f]t;
10. A chief fiapl oMmr of a county,or a public anministrelm appointed pursuant M the Summle's Court Prcnal Act
10. Any other permn who k acting on beleff 0 the maywhod and woo has executed a written Gathmmd pursuant ta Public Heats
Law Semen 4201iy.
GALL THREE of Me bpommg)
Ihi nereq affirm Met the thirty of Me dauesed does not trouble a badary, beXery me: power call, mdlmnNa Implant,
or radipGive device and that any such salamis were removed prior to Me exacu6on&g is AUMaNzaN Form. Failurewremove
Mau I1eme priorb aemalion may moult In M=to Ma cmma"aM cmnaWq personnel.
MMe,Norm Mal mandatory have been given to Tommy Murray r....ro,.m.ra.
regarding the removal of any mrsonal prgerty or other M'ng of value which any Mason egnMq Mi a aM(sway member N Ma
deceased wehes b preserve. Plus View Crem
is rat responsible hardly,removal of persmnN Items from Me consumer elms the remains oft"discussed. Personal lams Ito m Me
oonhlrsr cretin Me remains will be destropd by the cremmon process and cannot be mdeved after cremnlan.
Me M1ersq aNhwue Pine Newcranymry
No cmmab tM mmeim of Me deco .
finding oPnauu
Vwa hemby aulhed a the named mnaml director to prevails for dellvary,to and cremation q an afrema s
rsmamry, If deemed necessary in Me opinion of the funeral director, and to amend this form M provider the[affect name and
address of such aaumNe customary.
FINAL DISPOSITIDN
The person authorized to Mason Me crenated remains of the deceased from has contest is'.
Nerve M.B. Ki4mr Funeral Hone
Addrma: I X Main St,SouM Glens Fete NY 128m3 Phone: 516741Ls116
The oemaled remains of deceased WIN be dlapoSN of as flown:
III Southvde Came
n for any mason Me merson named Meet does not INe Wassel of Me mmmM Main of.
Pine view Cnmatury is autM1sized w gate puseadm of
Me remains to M.B. Kumar Fuca&Hone by highway
w w eM
In Meson or by negesrerl mail. gogm Nyb
DOS.IBg3.f gai(i m� Page 2 of