Hensler, JacK I. Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: PAXAPOW RETURN TIME'
DATE B TIME REMAINS ARRIVED AT CREMATORY: � llyITO
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
Katie A&SAAmeL
NAME: WK I wgEQ CASE 0
TYPE OF CONTAINER: Peu F jin1 tfeGlik cNoiUrf
PLACE OF DEATH: m I E .kNaoO) Pcu'Tv. RaRO( ufl¢REAuH�G.d� .
ESTIMATED WEIGHT OF REMAINS L CONTAINER_ IZO 11,
PLACED IN HOLD:PLACED IN REFRIGERATION: I$.UO Ph
DATE OF CREMATION: Ostia
TIME STARTED: 0040 TIME COMPLETED: /y�CBFQn
PLACED IN RETORT: I)" •11�MOVED: /IYOIII I 7'r'Oa
RETORT P IN WHICH REMAINS WERE CREMATED: Q;' fhks
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY: _
NOTE: THE CREMATION LOG sn.0 BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
OlIk
aw
Depamnntt WSe
NEWYORK Division of °^"N°N°yPLEkl Tema
AE' F ` i O cal",%em
OMRTIXITY. Cemeteries ygon Averm
1 x Intpwt
havolm as losal
Authorization for Cremation and Disposition
This Au mzanon Form must becompleted and signal prior to delivery of remains for cx tion.
Cats: OWM030 Number:
CMMSi Nandefaine V Creamery
Address: 21 Quaker Rd., Queen bury. NY 128N Phone'. C�61 746NN'Y)
CREMATION IS AN NiREVERSIBLE AND FINAL PROCESS.
Cremation is coal am by placing the remain of the demaesd add and mnfamer human the remains uM a remotion chamber whore
they am subjected to intense heat and dame. The host and human will and consulm averyhina emspt teem and nreral,
which an all Mat will be left Affair cremation.
Following aton,the comarory will Mks Novel efforts to remove all M me remains and once mandal horn the themetun
chamber, but and,minimal dust and agedue will likely be left behind. The cromurrry will secretary lrcid l and foreign matters l horn
this remage and me lnadencel and foregn malarial will be lowered ales mcured bylaw The cremalN remains will W mechaniCBlly
WlvedIDdInto all penis and platainb a designated container or um. Coma nmalnagenitally$MWlvari¢edurInD
sires fragment is mdognhede as skeletal(tsars.
OPENING OF THE CONTAINER
The uearral may only open the container holding the unoremated human remains In IITAed circumstances,such as A Confirm the
identity of the de0.asN or to encore that no material is enclosed which mitrumival employees or damage the emme PMMce N
human nines an delivered in a dwwxmmr which Is net suitable roc cnmoon such as cannlmrlal or novel rake The
maWq will ra M in gulre at the remains moved m a amdble commands before itaooeps Me M m. The cpemre Of
cosul wove harder or removal a antral TO will the contuuent Were awitness and Fall I»dam in pivary, with dignify and rests 1.
DENTF CATION OF DECEASED
Name M Resealed: Jack I. Hensler Mama) Statue: Mamed
Last Knvxn Addreu: 1T11 E Sermon River Rd., Warrensur9 NY 128M
Place of @alb: 171F1 E. SDM1roon River Rd , Warrervaurg, NY 128M
Sex: ®M OF Age: 72 ME, 07M511947 Dale of Oil W2112020 Estimated Wei 120
IPs eon of Wske tamer in which remain wul ce delivered.
New ENIand Cremation deluxe comainer
LOHINOL OF DISPOSITION
(Pirelli In xnbd oldstomrmn, infli QVE of firm Mlonittg)
I amM1N¢are the designated agent Of the deceased desivade d in a will orwmlen instrument ewcuhd pursuant to Public
Heats Law SeGan 4201.
-ON-
INie have no knowledge that For demased ex6Ned a written insWmenl pursuant to Public Hear law SeMdah 201 ore
will remaining ditt ,one for the disposition of his or ther remains and LM2 are the wool Nvina pnodry under Public H"th Lew
Bion@Ot and reverse right to authorrememffion of the aerosol ofthe deMased. MyMurmlatWnshlptod deceasedNas
a lox
Jill I. Hensler
OOS-1 hurt grev.IW20) Page 1 of 3
Authorization for Cremation and Disposition
(Iris from Me too content
Number:_ Description Sufflunift SMuse
t. Aµrson designated in wil pureuamW Public Hal lw funeral 4201(3)',
2. The sul spousei
al. TM supivirg domestic paMer;
0. My survival child eighteen years Of age Or after
4. AwrviNng parent
5. A wrvinng sibling egMeen years of age Or older.
0. A lawMlry appointed guardian;
T. My gersal(s)eighteen years of age or older wrWhal to share In Me Mate and who iPam closest In reletiomhip b Me deceased
e. A duly appointed fiduciary of We estate;
9. Ad Mend or relative who has executed a wagon statement pursuerat to Pudic Health turns SeNon 4201(T)I
t0. A MW fiscal oT4er of a county or a pudic administrator a WNC d pursuant to the Surrogate'!Coun FOced ure No,
has. My Other me who is acting on beholf Of the deceased and who hasesCuted a aAmm statement pwrovnt N Public Heats
Law Rdlon 4201p1
posaf/tay�ALL THREE often/oPowing)
W// INle hertby affirm that the sandy of the deceased does not Pontaln a baXery, hall pal gvxar sill. radloacttue iml
or verse ova device and that any such materials wares removed insist Me execution of this AUNw Om Form. Failureroremove
these forms prior b emmabon an"value In halm to Na ammry,ab and enxnetary MMOnml.
Ase P Meatermmatinetruulanahavebeen9ivenro David Alexander
regarding Me removal of any parental pM"e or mat Ming of value when any Person signing Maw or any family mentor A Ne
damned wales N preserve. Pine View Cremalo
is not octa ode mrthe removal mpenonal items from the cOnumero m Me remains Mthe deceased. PenonafitMieftinM
wMr er or wIM Me remains will W d troed by the cremation prauss and cannot be n4i Wafter cremation.
III Me herby authorize Pire
Crematory
to cram the remains w the d $0.
(Initial OPTIONAL)
Mahe hereby auMonae the named funeral director N provids for delivery to and cremation by an afternaY
tary, If deemed n n ecaary In the opinion of the funeral dlrvcb[ and to amend this form to provide Me comd name and
emmddren or such alternate aremabn.
FINAL DISPosmoN
The person awhoh:M to remove Me uemated remains of Me deceased from Me crenni in
Name Alexander-Baker Funeral Home, David Alexander
Mdren: UN Main Street Warrensburg NV 12885 phone (518) 523-2055
The oemakd remains of MceaW will the disposed Of all Md s:
Return to family
If far any reason the person manned aWre does not take poeae m of Me cremated emans.
Pine Yrew Crematory is ouMa to give POmslon of
mossessivis
Me remains AlexantlerAaker Funeral Home by delivery
in person or by reglaMmd mau, Jack 1. Hensler
D(Oa.tf aef(Rev. MO) Pen Pagai
Authorization for Cremation and Disposition
1na1/81lfl��r�ay Widening)
tole understand lFatil the remaire are net Gelmed within 120 days of me n,
Pine View Crematory, may dispose of Me weralns in
an tireparation manner. such as by scevedrg.
caDogr a CMTAIee1011ee
(gerONEWMe ldawirg) Alexander-Baker Funeral
An um b de uaM es a antaircrfor Ne cremarod remeina des Eeen purUesed ham
and is deseree d So fellows'.
IANe understand that if the um he too SM811b held the entire unmled remeira, an additional onto wMainer met be wN kr doper'
-OR-
IIIAn em is rot son pV al , W/e uMmtoW heat if no um in permit or Otllerwlee pmulded
Pine View Crematory will place to restated anni in
was"cw.evnl
a red temporary container her delivery.
The AUNWY n Farm area provided by David Alexander was executed 81
Alexander-Baker Funeral Home
3W9 Mein St1�cet, Warrensburg, NY 12885
jnvvw.A�
and is eared by Ne tonal dirMor as whneu b itsexecution
Me have recerve i a winnowed copy of MIS AuNrMzaWn Form.
no
inew
In contail of
by signing
he Me pron(s)iftedfied vince,and cme�pleten1N1are the 9 0 the Inter natllan computed en this AuMo re 1pon Farm and assumes)the ffonyung.
Signed MIS 22nd dayIN June ,2p 20
Doris L. Homier
971 E. Schroon River Rd Warrensurg NY 128M
NTNEsa:
David Alexander C/
nwer,vi rse.awn.wRi
100341
Vww,.w Jack I. Hensler
DOS-18984(Rev Ovi PgTe 3 of