Yeckley Jr., Robert Pine View Cemetery 8 Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME §AM 0 RETURN TIME:
DATE E TIME REMAINS ARRIVED ATCREMATORY: L/alm ilyMo
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
41-Li" 1pg5K0
NAME: ROBS �
! YE(VIN Op AGE
TYPE OF CONTAINER: 1;4fv LN 424ya D / Sfi.re� (LAIC( IF3g11�,
PLACE OF DEAT z 5. . S"T ^
ESTIMATED WEIGHT OF REMAINS IS CONTAINER XDl ZLD ITT
PLACED IN HOLD:
PLACED IN REFRIGERATION: 1^� 12ho
DATE OF CREMATION: **IIIrl 61zilio
TIME STARTED: Jim An TIME COMPLETED: 1LLSq�
PLACED IN RETORT: 1L#tAp(Gn MOVED: ---------
RETORT# IN WHICH REMAINS WERE CREMATED:
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN CS HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SHALL BE RETAINED IN THE PERMANENT FILE Of THE CREMATORY.
New"
Authorization for Cremation and Disposition mmwmasraw
e..mmmeraraa. a„wo"nwlw
wlsley iaaos
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ThOAetlrorrsaflFrn Forrrrmrrrt be comp Mel m stgnedpd rN delivery of mmeldg fOfdFYll W.
Dale: (ol i9 JZOZC1 Number " Slf
Crematory Name: Pone Yew Cmmatory �`1
Address' Owker Road. Oueensbury. New York 12809 Phone: 51BI745-c477
CREMATION ISBN IRREVEREIBEE AND FINµ PROCESS.
Cremation Is an1eE out by placing the remains of deceased and the container holding the remains Into a
cremation chamberwhereMey are subjectedto intense hemand flame.The herea and flame will Ialmrrte and ammume
everythi"mwpt bone add metal,which are all that will be left after cremation.
Following ere motion, the erematory wlII take Masons ble Him asto remove anot the remains antl 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 plared into a designated container or um. Cremation]
mains gene alM are pulverized until no single fragment Is rewgnlude as skNed Same.
OPENING OF CONTAINER
The crematory may only open the central holding the un-cremated human remains in limited circumstances, such as to
confum the identity of the deceased or to ensure that no material is enclosed which might Injure employees or damage
commonly properly. N human remains amdlFrered in a container which is not stumble far monsoon such as comments]Air
renal osket,the aemewry will require that the remains be moved Into a wfteble container beore A accepts the remains.The
opening of a container or the transfer ar removal of remains will be conducted before a witness and will be done in Privacy,
with dignity and respect.
IDENTIFICATION OF DECEASED I \ I
Name of Deceased'. "Ro11Iani-4 I All Stars:_
Last appear Addai 2A r,ltn niar�( (�L o p A Nb �il� 1?'Wlc�
/ Y n TI
Place of Dealh:
se, ,* OF Age DOB: /DJ79I1942 Dalem Dean:U11912070 EaemeLa igm: 2C01bli
Description of casket/wntainer in which remains will be delivered
Corrugated Cardboard Box with Plywood Sterol Model A 3MOB
PERSON IN CONTROL OF DISPOSITION
(Perwnls)in central of disposition, initial ONE of the fallowing)
I am/We are the designated agent of the deceased designated in a will or written instrument executed pursuant to Public
Health law section 4201.
-OR-
1, lMe have no knowledge that the deceased executed a written Instrument pursuant to Public Health law section 4201 or
a Ilc ntaining directions for the disposition of his or her remains and(Continued next page)
o aim-wife .oval . yCL�Cu
mrrwoa�� esarea
l am/we are the Parents) having priority under Public Health Law section 4201 and have the right to authorize cremation
of the remains of the deceased. Nadi relationship tome deceased is as bill
ormyrjrwnrt bwl
lhe list be
Number F Bescnpdon:
A person designated in wrging punuegies PUNc Heats lave sacdon 4201 (3);
The surviving spouse;
2a.Tax surviving decrease partner
3. Any survivbg antl eighteen years of age or older;
C A surviving parer;
g. A surviving addling eighteen years of age or older;
g. A lawfully appointed guardian;
T. Any persons) eighteen years of age or older entitled to share in the estate and who cycle closest In
relationship to the deceased,
g. A duty appointed fiduciary of the estate;
g. A close friend or relative who has executed a written containment pursuaMto Public Health Law §4201(]);
10. A chief fiscal officer of a county or a public administrator appointed pursuant to the Surmgate's Coud
Procedure Ad.
1Oa.Arry otlrer person who is acting on behaN of the deceased and who has executed a widen statement pursuant
to Public Health Lau§4201(7).
(;2i LLMILEE o)Lhefollow )
RLy I/We hereby affirm Nat the body of the deceased does nnet contain battery,battery pack power cell, radioactive
mplanp or radioactive device and that any such materials were removed prior tothe execution of this Authorisation Form.
!Faailure to remove these items ptlor to cremation may result in harm to me cremParadisParadisiacalnel.ata and Paradisiacal person
KL� I/Wehereby affirm that instructions have been given Cossia Rati p101W regardingthe
remarval of any personal property or other thing of value which any Person signing bebw or any family member of the deceased
wishes to preserve. carriromis Pine Yew Crematory is net responsible for removal of personal
items imm the container or from the remains of the deceased. personal items last In me withdraw Far with the remains MIR be
destroyed lay the musician pmceu and cannot be re W eved after cremation.
Ru, I/WeherebyautMdaebsaaam, to cromate,the remains of
the dani
FINALbIWSITIO
The person auMoraed to recaive the cremated remains of the deceased horn me crematory is'.
Name: Baker Funeral Home Performed
Morass: 1 I larifireagge 5tridestQuatensibury Newy Yedra 12804 Phone hall)Tg1-003
The cremated remains of deceased will be dispose ! of as folbws:
aewm to family to be detided
If bar any reason the peBen named above does net take producers of the abandoned remains,
Inmmwnurrel Pine V'aw Cremabry aaWhorrsed as give p0.aaeRagn of Cre remains to
d vamuunu gaker Funeral Home by delivery in person or by registered mail.
4rdlf'! 4
nosL Haze. mLLw m e coca s
(Iplll[I rFejollo1 wrn9)
P )JI IN uMeMnd MMRMemmainsarenOl�wiulint20dWsofcrttnatbn,
to ,Wxyl I P' V' G mafory may dispose of Me remains in an Matievable manner,
seen as by restoring.
CREMATION CONTAINERNRN
lod, (nwEpizitsfa wM)
An um to be used as a container he Me cremated remains has been purGaseb from Baker
FuMml Home and is dee ribed as release
LA Ve understand Mat if the um is We small to hold Me was cremated remains an additional rigid container Tay be used
formatively
-oa-
L1 An um has net yet been purchase. INN UMerstaM Mat n no um is purchased or otherwise Provided (mossi
�mml Y C will place the vemaledl remains in a ngid temeo2ry
contairrerflardsvery.
This Authonzarion Form was provided by Nmwbmnw.�m) - RaH
was exerted at wm,e nmre vmel 9 Me F ne IH
Imnvnrvomeeda+s*1 lafav to cr O b Vrk 12300 eM es agreed by Me funeral director
as wa eee to its enceenson.
Mind nave reserved a completed ropy,of the AUMomeston Form.
The persons) ManM1Tre0 Lesions Were Me persona) he conba Ofdsposifron, who by Wrong this AUMor¢etipn
Form, shasa s) as,Me accuracy ale oemNeterreas athe deformation "Already in the;ANhorizatlon Form one
euthorver(s) Me toregang. T
agnedthis aa ^� tlayof
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WITNESS:Classes Rafferer
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