Chamberlain, Sarah Fay Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745.4477 or (518) 745-4476
FUNERAL HOME: _ AI %AooF0 RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: LILLIBD Z.HO{(7
NAME OF FUNERAL DIRECTOR OR RE��GRR��ISTEREED RESIDENT DELIVERING REMAINS:
NAME: SI{MIN CrNAfr�F1�(�ynAJ /y1C48I1p -ISL
TYPE OF CONTAINER: /4- YIIJ(r PLACE OF OF DEATH: . i_ t VNIMVWC /WU 1 I
ESTIMATED WEIGHT OF REMAINS & CONTAINER I70 L /N1s Ib
PLACED IN HOLD: M
PLACED IN REFRIGERATION: 2Ya QI I
DATE OF CREMATION: �1 �I23ITP
TIME STARTED: _ I1IS TINS COMPLETED: (D:roan RRRryryry..,,,
PLACED IN RETORT: GIVING:
RETORT A IN WHICH REMAINS WERE CREMATED: ✓ ont awii
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.
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Authoriration for Cremation and Disposition
Inds AWg "Wn Form most be completed and signed prior b delivery otromahm,Reconfirmation.
Date: 06/2012020 Number:
cm "Name Flame Yaw Crematory �'1
Address: 21 Quaker Rtl. Cueensbury NY 1281 Proms, CSC 'Al
CRF nON IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremetlon is named cut by placing hoe remains orMe dewaW ant Its¢nklner Facing hoe remains Into a uemation chamber Mena
tlry an>uNxled domains heat and name. Tbv beet and hmawlN inclmmb and comm me everydaind aanpl bone and adds,
whach an all mod wYl by ask vM cremallon.
Following cremators, the cremaory all won personal eflwts to hall all of me remains and other mabnal hcm the cremation
Dumber, but some minimal dust and cathode will likely be Its behind. The chiral all aepVele incidental and Resign metedal from
Ma commend,and the model and edge mffidal will be dislsaei M as faded by Ivw. The oemedd remains will de meepaninlly
pwvenzermR small pieces and placed wo v dnianatel ¢nwrcrm um. Cm remainsgamralyvnpulvOvun81m
slrrgle fragment as occasional as slada ltissue.
OPENING OF THE COWMNER
TM man atory may one open Me wrdairwOol leg the unSremNed human re towns in IImXM Dmumslances, such as b confirm this
money otthe deceased orto ensure Mal no meledal is enDpeM Mich might Inryre employees a barrel Me crematory property. H
human remains an assumed! Ina contalnarwhlch hunt notable Reclamation such as Parasol or rental cadealM
scandal will requira dot Me owners Its Toed Into v suitable somehow bebre tt¢eepa Me remains. Theapemin eta
anteiner or Me transferor removal ofoposa will be conducted bebre a whness and will M done in shoddy, vnM dgrtity and reaped.
IDENTIFICATON OF DECEASED
Name of Decimal: Sarah Fay Chamberlain All bretus: WltliAswd
Lady known AWraa: Countryside All Home, M3 Schroon River Rtl„ Warrensburg, NY 128M
Planer CeaM' Glans Falls Hospital
Box OX IMF All 96 We 12111N1923 DeAdDnLh: W1912020 Ed we m 100
Nob it of raskd Mimr'0 whi mmaim van be M1Aivered.
New England Cremation deluxe Container
PERSON IN CONTROL OF OISPOSTION
({brmnR) h mMml ofmairm nmode ONE o/Iha socca 1
I wMVe am the deelgnatd agent M the command dnedow in a will or writes Iwo menl eacuad pursuant to Pudic
HMIM Law'�S/wam Q01.
,DR- tX -6
Me have no knowktlge that the dema¢ed exeCNd a women instrument pursuant to Public Heats Lbw Semon 4201 or v
we remaining directions for this dis ostii n M his or her remains and IMR are the peoon(sl having pdogy under Publk HdM Law
Escape 4201 and have the right to authwim common of the remains or Me demnded. WhOur mlvaonship tethe Mcxed Is as
bllows'.
Sarah Fay Chambal
DOS-1891ruf(Rea-mono) Page 1 of 3
Authodu loll for Cremation and Disposition
Pool 9om lM 9e prowl
Number 3 Deasiber.surviving Child
1. A mi dnlOnated in writing punueM to Public Heats Lox Satin 0201(3);
z They summing spouse:
U. The sumving damned par ,er.
A My arriving did up Mean sense of age a Wall
A, Aaurrtving Ifte :
1 A suMWng eflirg NOMtcn years M age or older;
G. AW1ult/eppoiMetlguertllan;
T. My Porsobsl aigManyeere a me or door amend!to small tM name and who severe dmat in Mpheral b tM de¢
ay
9. A do"firiend w a oll&ry s e who a"hen stalemat pursuant d Public Heats taw Section 0201(7):
10. A aid fiscal officer of a aunty or a public aimmishadr eppaddd ruraeM to me Sumgde's Could Procedure Act,
Na. My omer pecan who is acting an peNH of has tle eball and who has esauttd a whiten statement purwwt to PublA Heats
taw, Seamn 4201(]),
hadi
ALL THREE aftfdrrWng)
f) 0 View hereby Orm trine body of the dWesed pore not calWn a beery, pansy pack, power call. MiwNv0 implant.
ormadmarne dorm and theanry such mtleah were removal phi to me a tia dt is Aunsoffmr Fam. FuIunb Mr Q
tlme Items polar b comment try asult In harm to the annual and channel grsomel.
INbaMmmetinMaonsMeM gn nto David Alexander
royal may removal d any Mwnsl pcmldy a dMr tong of value which any ended signing below or any pull member a Ma
damns Weirs own" Pine View Crematory
Anneal
rs not responsdk brIts remdelNpenanel ileme ham meWmimrwham tM mmaindtM dewased Pe oreilbms Ice Inthe
w(^r�rdin�erar Wth ma ramslns WII M da4ayed by ma nemstla praass antl ants M reblwed aXer cnmstlan.
J. M hamW sutMrrze Pine Yaw Crematory
sentinel
b cremab Its mmah s of the drowse.
UntJ OPTIONAL)
Its hereby aumor¢e the named funeral director to provide far memory b and crema0a by an alamate
oratory, ndamad necessary In the opinion otthe funeral toaster,sod to emend note tom be proven to comet name and
address of such formers crematory.
FINAL DISPOSITION
Ttw parsec aumonmd to ramrve am vemadtl remains of me determined from the crematory is:
Name:Alexander-Baker Funeral Home, David Alexander
Ammsa; 3809 Main Street Warrensburg NV 12885 Phme: (518) 823-2W!i
The semi mature ofdismissed MI W disposed of follows:
Burial in Warrensburg Cemetery
If for any mason an bold named above pas no take counsel tore demand recent.
Pine View Crematory Is lade ed he give panel
m>wnmw
the remand Alexantler-Baker Funeral Home by Warner
we w
in acorn a by registered mail. SaraM1 Fey Chamberlain
aa.aao.»a
DOS-Matt histry O4l Page 2 of
Authorization for Cremation and Disposition
rinda/Ne rawwmgl
Q () LWe understand that n the rename are not aeimN whin 120 Gaya a managed,
Pine Yew Crematory may dlapwe come remainm in
an detriment manner,such as Ey sdattening �ro.mn
GRE"M COH MMEMM
(I rAwl ONEofNa ktlo edut
An um to the used as a cormunarkr Ne caamakd remains haswen punchiest(rain aexantlar-Baker Funeral
and is dasnibed as Mkas
IM1Ne understand that dSe um is tad si to had the entire cemaled mnems, an Odmmel Aped container may as used for delivery.
Oe-
1J11umismtyNWraa , me understand that M ro um is duchaW an otlawua pouMN
Pine Yew Crematory art dlam the cremated remains in
n+..otin
e Ilgid Kmpmry¢nmi nIX kr wNYy.
This AUNWhetlon Form was provided by Davie aexanaer was executed at
Alexander-Baker Funeral Home
MW Main Street Warrensburg, NY 12885
and Is egMtl W the wnrel direClOr as seemed to iLL ame vemn,xo+vxerrw
lMe have widened a compared ropy M the Augorhadon Form
The personts) Identified Was,heard the penan(si In conbol W Strategies,who W mining his Autlwriza0on Farm,a qst
to the accuracy and consumerists 0She entonretlon contained In Nb AUNarbatlon Farm and auNorYNal the forpaing.
Signed this 20th day of June p 2200
Donna M. Duell t„ / jn le
19 Jenni Jill loop, Wannsbur9. NV 12885
sn.so was.
IMXESS:
David Alexander
drbhsasara.ar*r ..
10034
Sarah Fay Chamberlain
taes�m
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