Schmidt, Margaret E. (2) Pine View Cemetery S Crematorium
Quaker Road
Queensbury: NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: _ a O C RETURN TIME: E ^,�
DATE R TIME REMAINS ARRIVED AT CREMATORY: L )ZY IZO )I')ury,
NAME OF FUNERAL DIRECTOR OR REGRISTEREO RESIDENT DELIVERING REMAINS:
_- . yuo BULTN
NAME: M eiift Er 5tHiilor / CASES ILO
TYPE OF CONTAINER:
�1
PLACE OF DEATH:
ESTIMATED WEIGHT OF REMAINS a CONTAINER_ /so )L
PLACED IN HOLD:
PLACED IN REFRIGERATION: 1
DATE OF CREMATION: L.� W25Ito q
TIME STARTED: . f' "M TIME COMPLETED- Z'wl h
PLACED IN RETORT: I:Wth MOVED: 3:pfH_ I%4EQF)
RETORT # IN WHICH REMAINS WERE CREMATED:
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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Temp Name NY
msinew
Authorization for Cremation and Disposition
Thar AUMwhacal Form must lay mmpbtae and Signed Mean rotlslMry of remains air Cr 2"on.
Date: WI2W2020 Number -71LO
Chemistry Name rune MBW Cremelm
Address Quaker Flood Oueensbury NY 12804 Fero: (518)745-1476
CREMATION I8 AN IRREVERSIBLE AND FINAL PROLE
Cremation is cameo col by pladnV Me remains mMe dereaeed and Me wmeimrM1deirp He remain¢ Into a uemeLmdgmbxwlwe
May are sublet to imense beat and hams. The Mat and game will McMerab and co eseryming µpill pone and edged,
x ich am all that will M left&her cmmagan.
Following cmmeliory the commodity will how reasonable Sorest remove all of Me remains and doer member Man Me oemmon
UdmMr, but some minimal Maitland residue will likely be eft behind. TM uemelory void Kparek Mddemel ale IpNpn mabdel ham
Me seeks and be Inddemal and foreign malenal will M disposed of as assured bylaw. They cremate remains will M meNam®IN
palveaxdimo smell Ideal and praised into a deagneed coal or um. Cmmaee Resume generally am puNelee used no
single hepmam is recognizable as sic ltalus.
OMNINfl_OF THE CONTAINER
TM cremakry may only dean Me container holding Me uncRmate human mmains in lined dreumma Nunn u to Mahe the
r4rpN dine deceased or to ensure that no answered is Mdose argon might Injure employees or damage Me Cameery praerN n
human meagre are dellverea es congelpr which Is noteu elsror cRmean such as careful or Rae waML the
cramadogre will ague hands remains M moved Imo a sulbpN consider Mtoa N¢Cepb Me remains. The opening W a
MnainM drlhe t2n¢fer or remdveldremaiN Soil be COM teul[elweewMe¢¢ano void oe dorein Favary.wM MgpniNandroyal.
IDENTIFICATON OF DECEASED
Name m Depend: Margaret E Schmidt Masai status Widowed
Lee K.A4Mns:71 Longview Drive, Apt 161. Oueensbury, NY 12804
Fla of DmeM:. 71 Lorgvgew Drive, Oueensbury, NY 12804
Sex: 13M OF Ape: 94 DOB: ON2611926 Dagearo Olik=I020 Estimate Wagon: 150lbs
Desorption of pakeVMageMer in which annual all be tlelirwel.
Buffalo Casket Company—Alt Container
PERSON IN CONTROL of DMMMON
(Porsm(a)M mifml o1r0.apuitvn, xr2'el ONE d NR/abwp)
x uMn 4ere Me dngrulea ager4 atlwdeveaatl eeelgaetee 'm a Mn orwtMen iMrunnm emcNe wRa.m a vapac
meSt Law section zm.
-OR-
IM/e have no broader that the aeaase averaged a wnnen instrument pursuant to Public Health Law sMgon 4201 a a
wIII Ixng alreWdM rorme anpoMian M ma or Mh Rmaim and I/we m the pnanlb)neWnp McrN under Public Health Law
Sxtio 4301 and have Me npM1l W auMonze c ema ion d Me remains of the removal MylOur mdsnonshlp title Mcease m as
MI
Margaret E Schmidt
DOS-1698-I(Rev. W2o) Pape t of 3
Authorization for Cremation and Disposition
Hhwrt from the list broad
Humber: 3 dearepon:hltl over the age of 18
1. A person integral N well masuant to Public He h law 5x4di I3o1131:
2. lM surviving spcuw',
L. TM Surviving domestic"at
3. Amy survmlrei id digital years of age or deer,
A A wrvlring Pacer:
5. AwrvnmB sibling eighteen yeah of age or older
S. AlwfidN Spicninted guaN'an'.
1. My peremis)eightmen free d age or older entitled to share in the emne and wMiiae coal in regional to the dewma',
!. A duty sponsored fill of Me wished
B. A does friend or relative and has exaued a whom counsel moment to ruled H OM low3 42m(7).
10. A MWfscal officer of a county or public admmehetor dhbmrd1 pursuant to the 3undiab's Court Procedure Act
1M. My otMr 0=0 who,is acting[^beheX d Me dewwW and wM hoe executed a wrMen statement cement M Fudic Wind
law Seeks 02011]I-
TTNREE of the ydbserg)Me Worst seem that the body of the de¢nsee deer nd contah a bandy, Wrary mal paver call, radioactive ambient
or hamoatiw beat Yb Met any rush materials were rtmovM met Is Ind exWbn of this AurypenA Fq Fall to remove
that qbr to combat my reach M harm is,the crematory said channel personalMe elfirm tied instructions have ken given to Mark JJmD iimofre
I.
mian
Wand g Me removal deny personal poorly or door thing ofyWe which any person signing Whoww my entry member M Me
discounted wishes to preserve. Pine View Cremalory
fie not responsible he the removal of personal erne from Me wMainer or Mom Me tandems of Me d aesd. PwedMl Mms M In Me
mpMl//n$$..o.wnh Ma rem.Iw MII M auMvk ter Ms cnmstlon pmcwe arse unngM mXevsd after cnmslbn.
Nye herby aufM1anw Pine View Crematory
to crwrule Meremahu allM Wcwsed.
(Ind Cadvcav U
LYn herby auMoril the waned funeral dirMorto prover for delivery Wand cnma0on by an abscess
towards", H eex lo ned necessary In Me opnn dM t / w un deM m this
l or,and b aand b form b whowidethe most name and
Mdma ofsuch alnrde coral
FINAL DISPOSITION
me Amon autlxviwa n shirr Me aemaed norms of this dnmse]form Me vxnel is'.
Herne:Margaret Jones
Morass: PO Box 187, NaMkill Beg W 1284d- FHgpe: (618) 188-2873
They uemated sheens of Mmesee will M database of as ftllm:
all at the family Cemetery
H he any nascn he person namod above does M was personnel of 1M oemetetl Met it
Pine Vew Crematory as actlgewd to give possasdan of
the ememsto Regan Denny Stafoo Funeral Home Wdefi.wry
m..wt.�.rww
in person orbs rental mw. Margaret E Behmitl[
rwsw�m
Fort Out(Rev Mum Page2 of
Authorizaitlon for Cremadon and Disposition
rnn�',m>/rww,�nm
�4V NVe uncommon em nits restam am and dared admin 120 Ways oforemebon.
�J Pine Vbw Crematory may eiapoaemmeivn.i�u In
m OwWx0
an devirvede matter, such am by amended.
CPEMATION CONTMNERNaN
(�Bj@I ONE o/me bAbwinB)
Regan Denny Stafford Funeral
um to Ca usedea a connlrer lathe command!demand has Eden WrmamW bondu..
and is deaaiEeW as bebus:
Mae understand too I Me um N lit amyl b neq 1M anpre aadsead amain, an additional dpd container my W mial for delwdy
ppN
M um is eM M puemeaef. IMIe tr4naleM mat it ea um is puNieeee sir mMexYe gadeee
U Pine View Crematory well dam Mn unmated mrransm
n+...ewwn
a ndMrmuary container W eellvmy
TEN Aumomaaon Farm was nodded by Mark J. NSimone was executed at
sw-mm.m,a.w
Ragan Denny Stafford Funeral Home
83 Quaker %ad,Queensbury, NY 1260
and a signed by We funeral cdeemr an drove M as eaaowuon
Nye have remiretl a ampbted copy of gas Aumordatlan Farm.
TM parents) Identified Eabw Islam Me andante)In coarml of e4paallon,wM by signing than Aulymmahon Farm,a 001
mde smunry and wmplamtese of Me Information amenlned In gW AYNewtradM Form add auMoMgs)the brpaing.
Signed!Mls 23M doof June ,m z9
Margaret Jones
PO Box 187, Kaftsoll Bay, NY 12844-
me>ewer.. w•
Mark J. DeSimone
n..aomm+.m.e+wnxar �.gumv
10919
Margaret E Stlrmidt
pr...ro�N
0 189"goev.0 0) page 3 of