Carver, David C. Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745.4477 or (518) 745-4476
FUNERAL HOME: AIEIwO¢➢ RETURN TIME: uuMM
DATE & TIME REMAINS ARRIVED AT CREMATORY: k /2N IW I�"MIIM
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
PA4 Rkx».OFO
NAME: DAVLO lhizyo JI 'CASES '7t.2
TYPE OF CONTAINER: CNW &yJ
PLACE OF DEATH: if F '1{iL ZAAMI ( OI.A< '--I 17m)
ESTIMATED WEIGHT OF REMAINS & CONTAINER 2SU IL
PLACED IN HOLD: tvx P_cl
PLACED IN REFRIGERATION:
DATE OF CREMATION: '1 N W2O( - TIN
TIME STARTED: .7'40AA TIME COMPLETED: 10:x6I
PLACED IN RETORT: O y:ICPM MOVED: q:sO AtlipIS(�7 �rflll
RETORT Y IN WHICH REMAINS WERE CREMATED: _ P to 4MVi
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN C& HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SHALL BE RETAINED IN THE PERMANENT FILE OF i ECREMATORY.
Mery V^rk5uu
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SEWYORK i)IVISIOR Of DlvlsloN OF CEMErenes
STPiE°F PeCmnmerte Plexe
° °° CemeteriesAllen.NY;231 COW
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Authorization for Cremation and Disposition
This aul W"Wn Form must has Completed and signed pear he delivery m rem•Ins far Newsletter.
Wide OW3I2020 Number 14z
Cremxary Name: Pine Vocest(Crignmatory
Audi 21 Quaker Rd., Oueensbu NY 120N Phan•: 5♦6
CRENUT10X M AN IRREVERSIBLE AND FINAL PROC ,
Cremation is wined aN by placing the remains of Me deaax!me the xnuin«hawing me remand I=a rlun mchamber were
tt i mM alectea m Inrema neat ana flame. Tb nwl,ndn.m•wln lmlrrena,M vomums evrymine nc•p[bone.M mini.
wnlenareagtlut ,Me MRaror cramkeon.
cFollowinghamber but warre i a dust vole take reawneoieeeoft eremove all dMeremains aN cant«mzunel from Me creauWrt
nd
Me
dth m odArauatd forsom ueternal ery de letlbusedo TMuemamry will sThemoiaranda en fwil be maur'ulwN
meremainsanameInciaenmlanturegn madesiwat[e aiapoeeeorus nC by low, ThegsnOmll remand Mnbemech•niolly
sinleUae imodmell piems and pia Niel lWoue ea mnumer«um. crmba rem,Im genenny,rt pulvtivtl urinem
tlnpla fragment Is recapn'vableusk•IN,1 Wsue.
OPENING OF THE CONTAINER
from Crematory may only open the consumer holding me unCM1vn human mrrarm in limited amummanws wch as m =ami the
deni &Me deveasea arm ensure Nat no muedal is argued which mght insure employees or damagethe vematwy mWary N
human remains am dol"re Ina contalnerwnlch a not subal forc Lion such as ceremonial or metal casket the
m.mrywen sawkwoame mmaneanmoved imo• cand scea MM b, odnzedon merval with
ore
mitaiaer ovine trenareror removal dremems vdu be raadudea mane a wdnau em ado a done m privacy.wits dgnnr and respect.
GEUnRCATIGN OF DECEASED
Name of Dewnee: David C, Clever fu lstew: Marred
Lam known Address: 15 Federal Flats Road, OlmstedvilW, NY 12857
peaty or perm Deceaseda Residence, 15 Federal Flats Road, OlmatedvllW, NY 12857
Sex: ®M OF Age: 90 DOE: DEQV1929 D Mdp .. 0ISME12020 EdlkneudvNgtM 150
gs oon or wMNwnsurer in 0"mmum wil ON bkwrwl.
New England Cremation deluxe container
x xman TIROL OF DMPOSRXIN r ro fvermn(al ' era Ormag m, BONE wore nwo iay
I image are me despnatea ease or the de W dengrNW in e wiil or some ImMrrent we PumsnM PUNic
Heats Lae Section 4201.
-OR-
NLo IMls have no MowlMge Nu me dews makowd a written instrumentWnuanl m Public Heath tsw Sector 4201 or
v wining dlreml Air Me NdPxiition a his or her remains am hand are me waonut hrvirg pnwty under Public Health 4w
Se:twon 4201 ant love 1M Wet W auMmue Common ad the where ofthe demaaed. MylOur relationship to the dm•ased k u
olbx
David C. Carver
DOS-1898-r(Rev. Ni Page 1 of
Authorlmdon for Cramatlon and Disposition
(Immn M10 Wtwbw)
Number. 2 Merely Surviving Socaushey
1. A person oevgmted manure Mrsual Public Has" l.aa'Sxtion4 1(3)I
2. They harder spouse:
L. The surviving tlOmeetr mMep
3. Any surviving chid eighteen years 0 pe or older
<. Awrvrving whoot
S. A surviving siding eyMcen years of age on
S. A loci appointed guanliart
). My persoms)e mown years M age or older armed to share In the aerate and who aware dot g In rWllmship to the pereeod;
I. A any appointed fiduciary of Ma ntatei
0. A dose Mend or relative who has exeuerol a wMlen marersem hMuanr N Public Health Law Section 4201(7)I
no. A ravel fiscal oTiWr of a county or a publkadminist apsuined pursuant to the Sunone'a C un Procedure AM
10s, Arry other moron who is actlng on behaff of me deo W eM who may easMM a written sla nt pueeuenr b PudiE Health
Law Sol I201pf.
((obi THREE of the kpawmi
Amer Mnby aRam mM Pe body ofthe dKFased does not ONMUM a berry, battery pace Hill, mdiOa Implant,
r 1we device and that any such m Wneb were rtmorc] proem has sncNion of rhu AUMOIOm Form. Follum Wremove
Mere Mms pMa to emn ion may muH In harm to tln cre Mq and Annual panonml.
_y�C Idle edrm Mn kuwcEons nave been given to David Alexander
newh ing the removal of any pmsonal peeper or other Ming of v*us which any common sell or any family member M the
demahed warns W creseM. Pine Vil Channe
is rem responsible ter the removal 0"e al items from the cantaner or from the remains d me decmed. Perwrwl items le% In the
comalnor or Wth the remains AN be destroyed by tot crxnetion promised said cannot b s Mrievad aM1ar cmmetlan.
�vla` IAimmmbyamhdrw P'na We CCrematory
s..,i®rwrv� W crenate Me remains W tlw deceuad.
(ini OPTIONAL)
IM hereby, aurhoNa the named funml diMorto provide for delivery to and cen4tlon by an aNmab
;M Wq Hdowdr! necmary,in the apinlon of tM WmrN director,and to amend thdo term to provideme correct name and
address Mauch alternate cremamry.
FINAL OISPO SrtION
The named mhonral to rsa'rve the aemadd remains of the demased hen We whmarory is'.
thameAlexander-Baker Funeral Home, David Alexander
A m" 3809 Man Street Watrensbufg NV 12885 pham (518) 1
The cremated remains of ot Wit be dlsp of as Moore'
Return to family
H Am rry most to person named above does not take passesaion Of The vwmYd rrimim.
Pine View Crematory aaumx to give sore ion of
M mmalnsM Alexander-Baker Funeral Home by menary
wro
In person a by mgmertd man. David C. carver
oos-1all(R , 114W prawn Ficap N3
Authorim ion for cremation and Disposition
r�nre wrowmy
1CdAve undmatand mat dma lamams are nmwnnm madden fmdwsaamr.ron,
Pine Uaw Cremator mey diepaee mine remanam
an InemevWe manner such as W scafteril m wro..ud
CREMATION CONTAINERNRX
(�I pNE other Asti
Alexander-Baker Funeral
An um th he used as container for the vemeted remains has been pumloaed"in mono
and is described as sodowa.
IM1Ne ogsrroll mat it me urn a too email W ME me earth anon"remains, an Wditiwwl Mat comer r may W ual for Moody
-OR-
�y(-An um le net yd WWMnJ. IM1Ne undeNSM IMllf rro um b qucnued aa0invdee proNded
11 Pine Yew Crematory will place the cremated remains In
a evil temporary cordeiner for dervely. m+ucwsen
This Autlwrinlbn Farm was provided rry David Alexardler was sexual in
fino,woom, is
Alexander-Baker Funeral Home
38D9 Main Sheet Warners lg NY 12885
,se�
and is signed"a Neanl Mat as Mrcas W itsexeouron
IAJe M1aw coal a completed copy of Me AuMos4al Foam.
Tp perea st lateral below isemtlN pereants) In control 0 dlspoa ,who by signing that AUMor/mMM Form,effects)
tome accwacy,arW completeness of tM Informatlan considered In Nb Aumwleetlon Form add authorlaets)the Ideal
Signed mb 23rd day of June .20 20 .
JoAnne Carver
m sinfail
15 Fetleral Flats Road, Olmstedville, NY 12857
rmmsm.aa.w. ea.sw
w ESS: /O
David Alexander
0034
David C. Carver
lr.aa.�N
DOS-1898of IRaw, 04rz0) PW303