Barnes, Gary D Pine View Cemetery & Crematorium
Quaker Road
QueensburyR NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: �MPE. .{NKA/ RETURN TIME:
DATE 6 TIME REMAINS ARRIVED AT CREMATORY: L121 Ito I' FO Ftl
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
OJOuc BMAP IL
NAME: cm BAms I CASES ,dy
TYPE OF CONTAINER: Aw RV- L9 bDl
PLACE OF DEATH: I I.dY STSF.LY 1 SLLAIONH -yi LA IM MIL
ESTIMATED WEIGHT OF REMAINS S CONTAINER 1A rIC l.Ye
PLACED IN HOLD: t,w Ih
PLACED IN REFRIGERATION: b/dPrDO
DATE OF CREMATION: Lhrllb
TIME STARTED: II JD _TINE COMPLETED: IZ•BKTI II.
PLACED IN RETORT: II'YORYI MOVED: R-Mf� fywfh
RETORT N IN WHICH REMAINS WERE CREMATED: QRLZ
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE:THE CIRMETION LOG SHALL 011 RETAINED IN ME PERMANENT FILE OF TIE CREMATORY.
IW
OepaNnert of SGb
NEW FORK Division of orvMl oow C x°Mu..Mor
6rxrtoF IN c RI
""D"T""Ir_ Cemeteries
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Termho ¢:ISE14N6zze
Authorization for Cremation and Disposition
This authorization Form meet be mmpleW and signed Our aelMry mmnalne fair era"On.
ONE, OGyMm020 Murray, -1LJ
Chrul Name: Pine Vow Cmmatioy
MdM 210mker Read. Omanebury.NY IM04 Phone (518) 741s-4477
CREMATION IS AN IRRE $18l AND FINAL PROCESS.
Cmmalun is mr out by placing the remains 0 to deeaa a aid the runmircr hol irg the remains line a C abon chamber
They are mbledM to intense Wan and Rome. The M1ot and Rune are lncimmb and Consumes Oding except bom and MNl.
youth are all Mat oil I W MR air cremation.
meowing Cmm mon Me crematory will take reasonaae encoder rano ve all prNherta and other material those VbeRmanm
chamber bbuta som minimal dust ant residue will uxeN L'e left CMind lM Nearly vnll ceparamSadism am lIX Omammi M1an
Me remain and Meimacendl and overall matenal will WdispCYd Was repuiW bylaw TMaema mmalns MMbemx nimlty
pulverized Inch small piems and placed lino a designated win lmr or um. Oremabd reMlns generally an WI"Md man W
single fragment is rembrimble ea SMIb tissue.
OPENING OF THE CDWAINER
The car ebry may only man Me container holding the unLmmael human remains in limited Comm9enms.such as to confirm Me
Idem"the demased!old all Malts mate In mlosed which might injure employees ordama]e Me aemNory propaM1y. H
human remains am delivered Ina Container which Is not suitable for cremation such Ad ceremonial or rental cYbt"m
cmnamrywlll require Nettie mmsim be moved Inch a eultable container befom Recmpsthe mmalns. The opening We
contaimnOr Me tanasror mmwal Wall le art be conducted team a volume and win be Am in poetry etry,with difininand sesmct.
IDENTIFICATION OF DECEASED
Name of Deceece0. OYy O Banes Mantal$ s: Crashed!
Last Nnovm AMWN* As FOR Ua aSprings, NY USES
Place ofce as Feats 5ammga 5pmga NY 12M
sex Elm O F Age. 75 ooe: OM611945 Date W Dell o"azlmzo EaamaW weight
MaMpWn WmsM mlYenlm in"a remains off WE bMarM.
Cardboard Box wMlooden Base
PERWN W CONTROL OF DISPOSITION
(FirmMs)M mWM W dVp ..Mind ONE or Ed MW✓Mgl
I whim am Matle¢ynated agent W Me mmmsE dmigmW in B all a vnMen ima eM evewW pul ad Public
Health law Somn 4201.
IMb haw no knowledge Mn tin demasm eaCNM a whin instrument pul In Public Health Law S on Q01 or
W II mMno direcrm tar Me dbpminon of him whe,remains ant IMe are Theygmon(s)more under under Public heats Lew
SaAon 4201 and hew:to Nitrate of Ma remainsot Me Mormad. W10urmWOomblpm Madnmesdsas
blmw
Gary D. Barnes
DOS-lWast(Rey Dili Pape 1 mJ
Authorization for Cremation and Disposition
once ficm th any emend
Number 5 Dmsvgeon GulBnne Sams(gever
s. A Mason oetianakE In wrong Pursuant to Pull o Neale lax Sent Q01(3)
3. The surcving spouse:
L. Them inng domestic Wa r;
i. Arry Sor,mg can epM9en years 0l agaor older
a. Aanrvbiy pal
6. Aaurelvling sibling egMeen years M age or alder,
S. Alm lly appolnRo gumkimnl
T. My preard 5l eighteen years of no or clear entitled to sham In fire e9 aN and Vase answer In ml ShIp to My demon]:
S. A duly apponteO Mucury W Ne asrab;
S. A does Mend or nelahN"aled,miumm' a wmlen statement pursuant b Public NaaM Law Section 42011T):
10. A cof fiend otfim Ol a coumy a a pudic memmistmbr appoil pursuant to My Gunoybl Cout Pm(gouR Act;
toe. My other person one a mong on behalf of the ordered and who has exewkd a wMM1n sbbmonl pursuant or Pi NeaM
Lax Sub on Q01H)
grz igu ALL THREE Of ere rW'wnrg)
li he"al Met the bNy,of Me tlereesed Ideas not comen a oabry, battery par, power cof formal mplant
or rmdloa@ve deuce and ewe any and compares were remove pear b the examen n of this Autlwrhatlon Farm. failure mmaw,
Na prior to mmaoon may muN In ham No Me crematory and cnmmory pemon".
note arm than lnsMaoms hare been given W Rolland G. Han
reua ing on remorel of any Pursonal pmpep or cos thing ofMue wfiN any person sgmarm new or any lands member Of ow
deceaud washes to m¢em Paris View Cremalay
is rim mePunlble for by removal of poolhems ham M1n wMeiner or Form M4 remains of the demand! PomnN XBmsIaR In Me
wtrmr or wxh M.memory an Per Ma"W by Me mmnWm pmue and cannot Ea reMsred May cromallon.
IAW Mnge fficto a Pine mar Cmnabry
NO cmnab Me realm 0 Me daeeesad.
(Iy ai OPTIONALf
Iowa here by authMu Me named bneral i imbr to pmAde for delivery b and crematlon 4 an ahmate
adaery, 11 deemed necessary In Me opinion Qi Ngl OIMWr, and to amend Mk form M pm na vMe Me comM me and
dma m of such aMmm annual
FINAL DISPOSITION
Tiepawnauthormal to MMar MB UNn remains of Me�aseo Fan the a M u'.
Nam, Comparisons Furcnl Care
Arkansas. 402 any Ave. Snebga Sung& NY 12W v0ona_ (Slipa9ai0a<
They cM ream ins Mm® am be dupmso of a6 oulona:
REIVRN TO FAMILY
NMany mea nee ttmn named aEme May and bae methanol Of de commend mmaiM,
FmY Cmnelwy is euMMza]M gain Wswicn0
Ma mneimad �p cow Fuew Cate, lm yyp pony
n++ wwrru
In anon Of by reglenred mad. Gay D. Bacon
00S18n((Rev.0440) Pre Pall
Authorization for Cremation and Disposition
(i�wMeroxowngl
Aft unWm hot lire mrsaim any net deal mean 130 days of=when
Pine Ypw Consumersn may alapme of May remains In
an IrMnevable manner, team or by samurai Mu»
CREWTIONCOWAHEMRN
(addle ONE olme blbnenp)
An um M M meet as a octal or the orentabE mmtim has mean Wrdia mail
and is mosvLdl ae lowers
INA uMentlnd Nat If the um a Me mall b MM tlmentln om remaNs, an Wi al NO"New may the used!he EelNay.
cpR'
`-->I An um Is net M prrWaeO. Inner undrana E Nat M ro umm puMereE or corelMae pleadM
Pine Yew Cremalary All pace May cremalM by im In
uw�wcmq
a mad temporary comes nor for Moral
This Anthem asion Fomr wY Arrested by RaIbM G. Hop wmettuRedM
Compassmde Funeral Use. Inc
W$ Rare Ay., 5aratoaa Spurge, W 12586
lr.,�.xxxxxvl arrive Niby Me Nneral consider my wl0ess b ibexecution 0
IMh One received a ccmpldeE copy M Mir AWho on Fonn.
the penon(a)IEendM Were islaye Me periamod In mnh of dlapmlNon,xfio by a mIN any Auilro on Fort wassms)
W Me accuracy and mmpldamsa of the Information mnlalmE In NY Astronomical Farm and sumxaMmPHMe formminp.
Snitthe 30M dry of
Swsnne Penney j
31 Union Ave,SeraNpa$pimps, NY 130%
All
'MTNndRdta4ntl G. Hop
p11535mvmmuwim
Gary 0.Barney
008rail(Rev M/ID) Frosi