Sidusky, James Arthur Pine View Cemetery & Crematorium
Quaker Road
Queensbury: NY 12804
(518) 745.4477 or (518) 745-4476
FUNERAL HOME: jIR K RETURN TIME: y DATE S TIME REMAINS ARRIVED AT CREMATORY: _ VIZY IZD Z61)Pn
NAME OF FUNERAL DIRECTOR OR REGRISTEREO RESIDENT DELIVERING REMAINS:
loop
NAME: rAA"tS 6t 05ry CABER '7LL
TYPE OF CONTAINER: F/AIPLI cite l Q /C,akAd
PLACE OF DGTH: "V 1 TNu FP `.YI (ex I
ESTIMATED WEIGHT OF REMAINS 6 CONTAINER_ ZIT d
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION: eIj IjD
TIME STARTED: i qffin TIME COMPLETED: Alp
PLACED IN RETORT: -):YSilH MOVED: 8:35AN 0.5�rl
RETORT R IN WHICH REMAINS WERE CREMATED: P- fBLR
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE ONE CREMATION LOS SHALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
/--I eperbnentev W D
_J NEWYORK I Division of oM510NOF CEME1FPLO,
STAIEOF onzeUMU IES
W Cemeteries m m,l �.e
ALI NY t
pro :a1g<xeaze
Authorization for Cremation and Disposition
TNeaurlm. fn Form must be COMPIMl all signed Prior to delivery W remainsfor mmNon.
Date:June 24,2020 Nurt �4y
C.M.O.Name.Mne vkw Cmmalwy
Mdmes:Quaker Red,Oueembury, NY 12804 phppe: 5111-745L77
CrtFIVTON IS M IRRE MISLE MD FINK PROCESS.
Ca al n is Canned out by placing Me remains of the cautioned and M ,consumer holding Me nmeins mic a transition damper where
they an subjected to Imense heat and lame. The heat and flame will Inner and computed merger eaaapt bare and am,.
"II an all that will be left tiger MatMtipn.
Folicame common the category WHO take mesonabk WOM m mmave all of Me renalm and other material from Me formal
member, but come minimal dust and residue will likely be left Edit. The amatory will segram contrast and foreign rematlsl M1an
Me remains and the ireidenml and foreign manurial WI he disposed of as required by law. The vemated remains aril be mac al ims'
rulvenzed Into small pieces and placed Into a designated mgemerw um. Cr oW remains generally am pules d uMll no
NnSWhegment IsreoognimblemskeMll ua.
OPENING OF THE CONTNNER
the crematory may only Open the depener boring Me untrimmed human remains In limited clwmetanCAe, such as to confirm Me
kenmyW Me deceai into ensure that no matebalb enclosed which might injure employees or damage the M"pmpeMp If
human remains an Wiivered in a"Merrier whim Is net sulWr far namallon such as camnonal or rental coding.the
gory will require Mat moved he remains be into a suNsb"Container Were it accepts m µe remains, Theo mg o1a
crematory
timer or the transfer or ramwal of remains art l be conducted baron a witness and mil be done In privacy Mtn dignity and respect.
OENTIFICAnON OF DECEASED
Name 0f D ¢mound',James Agar&dully l4grlel state : momI
Lead Known Attorney:135 Hartman Leap.Cueenmury, NY 129
Platt of De arm Nnlhway, Town of Lake GmW
Sax, 0M OF Age:76 t3og,05/20/1944 Date Of Oem:OW21RO20 E9imwwI Weight 6
description of wekegromidner in which remains MII be delivered.
Minimum Cremation Casket, Pine/Cardlward, Florence Casket Co.
PERSON IN CONTROL OF DISPOSMN
(Peran(a)in mnMdMspoaMa+. inilg ONEo/Me/a4owing)
I armed ere Me deskJnkm d agent of the decreased deelpmted In a will or vrtltmn Ind ment gemmed pursuant to Fumy
Heats law Sectkn 4201.
1RR.
l]GB lose have no knowledge mature de¢essid executed a wntlen instrument Wmmmt to Public Field Law section 4201 w a
WII communing compares;for me diFii n of his or her remains am I/weare Me persenl8j flying Friday under Public Heam law
Setlien I2o1 add have Me right to authorize Cremmon of Me remains of the doWa8 . add Our relatlonMi W Me deCoa Is an
Ma s:
James Arthur Sidusky
WSlgt f(Rev, 041 Pagel of
Authorization for Cremation and Disposition
(InseR lmm the ad babes)
Number: 3 Beacnpucn: Summing BaugMer
1. Agrson designed in swung pursuant to Publt ROOM LOW s na2ot(3):
2. The amounted spwae:
M. The surviving domestic Penner:
a. My summing child aghleeo yarta a age or Older
a. A summing parent.
S. A summing amllrd eighteen years at age m case.
S. A Reasons appointed guardian',
L My"man(&)eighteen years of age or older entitled N sham in the seven and who lean¢ closest In relationship m Me tleCNW
appointed g. Ades(riand or m estate
at who has ezemletl a Will slabmeM pm Ruder
Pursuant 0 the
Health Law Section Procedure
Ile ANIeIMelrson e a wunty m apublof ureMe dismissed
anstralm d ardwho has executed
Me 5uften a §Coud Procedure Public
tpa. Any gMrperyonmTor is eNrg an behellolthe dereeael eM who has exeatedamulen sralemem purwentm PubYC Heats
Law Secuon 420106
Mnnhaf ALL THREE or the/rvbellnp)
kbR Wee Will affirm Met the fitly Of Me densaeed tloea not contain a sanely remains park, Power cell. 2dlpclive Implant
Outsmart device and that any such materials ware removed prior to too execution of Mls AUNw &Wo Farm. Falluretaremove
New I1Q press MyemmWon may MUM In harm b Me amWwy and aremalory par ml.
(3 KDRAW arm thahnshuchona have haven given to Todd c. elver
m.e+ri.ma..
regereing the rengval of any personal property or other thing of value which any perwn wall be ow Or any firmly member ad Me
demasetl wiaMa ta preserve. Pine V'rew CremNwy
is net wponsibe for Me removal of Personal Rams hem me mMelnerm tram Me remains drum contract Pnsonalfomele111n Me
mMInUw or wide Me remains Will ber destroyed by the aremaxen prt sand cannot m Ma ed affair cremalien,
KD& Myaherebyam ome Pine view cmmatnry
(wass",r.ml
to amnrab the mmaina al the mam.w.
ui OPTIONAL)
Mae hereby authorize Me named funeral director to provide far delNery,b and cremation by an albmNe
erematsry. If will necessary In Me opinion of the funeral dirMar aM to amend arm form to provide tlN comet name and
amrw of such alternate charms .
FINAL nISPOSRION
The pmsm allthOMW to reMivs the me d remains M Me tlereaxtl from the aemal Is:
Name: M B. Kilmer Funeral Home
Audrase: 82 Broadway, Fort Edward. Ny 12828 PIore. 518-74742N
The cremated remains of bemased will be despas ed of as RAMS,
Ruralin Samatel National C
N For any reason the paMon Mmad amre does not Arm powerful 0 Me aremal re M.
Pine MI Cnmahay, n authorized b give paasessmn of
rymmym.w
the remtine b M.B. Kllnar rumored Hgm by del'wary
in prawn or by regiWeM mail mow James Amur SMuaky
pwsaw..a
OPS1886 piefor M4RXM Page 2 of
Authorization for Cremation and Disposition
( Me/Nbwiag)
KDR Me urAaraMna natu VS reforms are Mclalmeiw in 120 days dissolution,
Plan van Crmatory may aYpor aNe mandate
wc.Nw
an lrteNevable manner, such as by smMMmg,
CREMATION CONTANEBNBN
(MNed ONE of the tvasway)
An um m be used as a comas nor for Me command remains has been purtheMd M1pn
and is M acribad as MMM:
Me understand that If the um 6ba goal b MM MeOman uerreldl remain;an eMPoonel Mild angina may M used Mr(MIUMy.
pp
KD An um is not year purcbned, Ma understand Met X W um la punnaged Of otbeawisa Panded
One View Crematory will place Me cremated remains in
I wa"e.en
are id Mmpwary waelner M delivery.
This Awhorin4on Foot wss prwNW by Toll G. Kilmer "a executed at
6w•'+nrarrwW
M.B. FIImer Funeral Home
Ia�urre+amV
82 Broadway. Fad Edward. NY 12820
irwursanarl
ends signed by Me Nnnel director as futri To he esxuion.
Me have recurred a command copy of this Authorization Form.
The diamonds) ideeUned bean ielam Me person s)in wMIW ofdispovlBM,wM by signing MIS AUMorizatlon Form, aWvNst
to Me accuracy and damplebnevv of Me attenuation owmalned In This Aulbotln Form and vuNorlm(a)Mele died.
Signed Time 20M day of June p 20
Kimberly Buyer K! ('
ThwarrAmArtaina
2 Ryan Assets. Quaternary, NY 120N 1
o3a8i
rwmo.a�brm. a,+..
wtmESS:
Todd G. Kilmer
n1.mo,.rwrwsr».ea.w
11879
m+om+m Janes MMur Stability
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WS1998-1(Ini 04W Paga3dii