Morrow, Diane Lynn Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: . DIAOL RETURNTIME: =ASH
DATE & TIME REMAINS ARRIVED AT CREMATORY: L10170 3. 3011 /
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
Kus-P4 KAS90
NAMG DSNN� PIOIRnnCOw L I GAS! 0 I�J�
TYPE OF CONTAINER: //Y1P NYf✓I ;L3S�
PLACE OF DEATH: 3S e%hEyO. C m 4+ tj 170,E((
ESTIMATED WEIGHT OF REMAINS & CONTAINER to UX'
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION: 174170 �A
TIME STARTED: T1JP� TIME COMPLETED: /, T�Arl
PLACED IN RETORT: /' MS MOVED: L10 A�I
RETORT N IN WHICH REMAINS WERE CREMATED: I ' - IFvL'L
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 4S HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SMALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
kutho)ization for Cremation and Disposition awe,°,reveal
pnp Comment Plaza,
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e unn
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This AUM zadw Form mart be cmmpb end sign"prior to defizi of remains for cremation.
Date: W131to Number 7ep
Chemafery Name: Pine slew Crematory
Address: OuagerRoad. Oueensbury, New York 12804 Phone'. 518)745-04]]
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation Is carried out by placing the remains of the deceased and the Container holding the remains into a
cremation chamberwherethey are subjected to intense heatand Flame.The heat and flame will lninerace and consume
everything except bane ant nmlal,which are all than will be left after cremation.
Following cremation,
,the crematory will take reasonable efforts to remove an of the remains and Other material from the
cremation chamber, but some minimal dust and residue will likely be left behind. The crematory will separate incidental and
foreign material from 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 pieces and placed into a designated commoner or urn.Cmnatad
mains generelly arc pulverized ulNl rw Yryle fregmeM Is mogNzable as s"il iName.
OPENING OF CONTAINER
The crematory may only open the container holding the an cremated human remains in limited circumstances, such as to
confirm the identity of the deceased or to ensure that no material is enclosed which might injure employees or damage
crematory property. If human remains are dwire In a container which Is not suitable for cremation such as a cerebraNal or
rental cos the crematory evil requlre that the remains eve moved into suitable container before It aarpas she remains. The
opening of container or the transfer or removal of remains will be conducted before a witness and will be done In privary,
with dignity antl expect.
CATION OF DEC sr�s , I
N ofD 0' . 11 IOk'CbT-� Maritaista )JAc L,2qr
Lest Known Address: # lA� N �'
Place of Death�S �iK A1�' Q�cn, all � \ �I
Se,: DM iXF age DOB: OLAllI fig page Of Ceath:�, a/ PadmatatlNVeghC itzZ I65
Description of Casket/container in which remains will be delivered:
Corrugated bard Box with PKiewband Star mark Model R
PERSON IN CONTROL OF DISPOSITION
(Personls) in cvntml of disposition, initial ONE of the following)
I am/We are the designated agent of the deceased designated in a will or written Instrument executed pursuant to Public
Heafth law section 4201.
-OR-
[`�) I/We have no knowledge that the deceased executed a written Instrument pursuant to Public Health Law section 4201 or
awillcontaining directions for the disposition of his or her Thai and )Contjnued next page)
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oonaaaau(Ran.pvw Prn= a
I am/we are the p arspnls) having energy under Public Meant Law Aide 4201 and have the right to authodm cremation
of the remains of the deceased. all relationship to the deceased kasfollows:
(Imenlram the list Ylow) \ �
Number�oeserial ZCA^YA
A person designated in wMing pursul Public Health Law sMbn 4201 (3);
2. Thesurvivingspouse,
2a.The surviving domestic parbmr',
QAny survival child eighteen years of age or older;
4. A surviving parent,
S. A surviving sibling eighteen years of age Or alder,
fi. A lawfully appointed guardiaq
1. Any percents) eighteen years of age or Oberenb0ed to share in the estate and who lmare,closest in
relationship to the deceased;
B. A duly appointed fiduciary of the estatel
g. A close friend or relative who has executed a written statement pursuant to Public Health Law§4201(7)'.
10. A chief Local ofiwr of a county or a public administrator appointed pursuantto the Surrogate's Court
Procedure Ad:
1 W.Any other person who Is daring an benalf of Me addresed and who has executed a wafted statement pursuant
to Priam Health Law§4201(7).
((pyjll AU TMREF Of tne)albwMgf
Jl I/we hereby affirm that the body of the deceased does not once in a battery, battery pack, power cell, red load ive
implant, or radioactive device antl that any such m income a were removed prior to the execution of this Authorlaatisn Form.
held re to remove these trades prior to aemaabn may result In harm to tot crematory and erematary,wiredraw.
�0 IMehereby affirm thM inshNGlans have been given toµnnawmmr.wwp Gsstr RONerry N1410 regarding the
removal of any personal property or other thing of value which any person signing bebw or any family member of the deceased
wishes to preserve. Pine View crmatoN is net responsible for removal of Personal
items from the onlainer or from the remains of the deceased. Personal hems left In the container or wife the rtmalm will he
destroyed by the vematbn proreu and saint be rMeveC after cremation.
I/we Mmbv students ammonmmel P' V' to outside theremdms of
dw utl.
FINAL o sposmoe
The person authorized to receive the cremated remains of the demised ham the crematory is'.
Nam
Address; 11 Lunfaverts Shmet QuqgmSbury New York Phone: (510 7g1b000
The crenated remains of deceased will be disposed of as(allows:
Return to family to be decided
If for any reason the period named stands doper not fake possession of the crecrade l rernalna
tomwlmremw y' C N auNpr¢ed b give possession of Me remains to
Avm,mwawwww,wp 9aker Funeral Hom try\]delivery In person or by registered mail.
\
m �r
DD&UPNv ten.CLAM unm..rrr�w�a o. 2 I
an_eiol Nkjolbwiyf
��pJ,� INJe understand Or at if Na remains are notcla need w in 120 days of cremni
(uom..l Pine View Crematory trey dispose of the remains 1n an irretrievable manner,
such as by scattering.
CREMATION CONTAINERNRN
labor ONE o)me following)
M urn to the used as a container for the cremmea remains has been purchased from Baker
Funeral Home and a described he follows:
IMg underhand that Othe urn is too shall to hold "entire cremated remains, an adCOionel rigid container maybe used
for delivery.
ON
-SZLAn urn has not yet been purchased. IMer understand Mat O no urn is purchased or otherwias provided rusmawr
"inoi pine Yew Crematory will place the cremated remains in a rigid temporary
container for delivery.
This Authorization Form was amended by fN�ay.m.mmel xa Palfenv p161C0
was executed at isrM.orwm<„om<i Baker Funeral Xom
(i.xwn 1 eensb end is signed by the funeral direction
as wiMese to its exdurnar
WJe have received a compleled copy of this Authorization Form.
The persons) idenfiTred below issue fhe persons)in consul o/Wsposition, who by signing this Aubrorrsafbn
Form, ahest(s) to the accuracy aM completeness of the inbrmetion "Earned in this Authorizab'Oir Form and
auMorize(s) me foregai
Signed this `3�2^� dorm 2g—\�� 9
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WITNESSChase Eaffartz
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