Schmid,Albert Frances Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: flpYSO_ _ RETURN TIME: M LE
DATE A TIME REMAINS ARRIVED AT CREMATORY: Ox PID 35111
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
1 KEL51;4 fiLASEO
NAME: Albin- S" m;i II 1 /CASER 161
TYPE OF CONTAINERL: [ ✓�LA /R1IINr/ WI(' JI1 II N4 I) wwp
PLACE OF DEATH: (II.F tS 1Is %1451
ESTIMATED WEIGHT OF REMAINS E CONTAINER 140 I�
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION: L)AI$C
TIME STARTED: /1:56AQ TIME COMPLETED: �ZRIII�OQYI
PLACED IN RETORT: 12AMj MOVED: II%RIWI_II L9i Qt')
RETORT # IN WHICH REMAINS WERE CREMATED: PATS
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN OS HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE THE CREMATION LOG SHALL RE RETAINED IN THE PERMANENT FILE OF THE CREMATORY
Authorization for Cremation and Disposition "you
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Date: 6 11e lib Number. 16�
Crematory Name: Pineviewc
asdarbv' Quaker Road, Oueenabury, New YoA 128N Phone: 15101]15-C6T]
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation is earned out by placing Rre remains of Me deceased and the container holding the remains into a
crem
ation chamber where may are subjected b intense heat and name.The heat and llama wlllhandsome antl
consume everything except bane and metal,which are all that will be left after cremation.
Following cremation, me oamatory will was reasonable efforts to remove an of Me remains and other materiel from
Me co motion clo mbeo but some minimal dust and residue will likely be bM1 behind The crematory will separate
modenml and foreign materiel from the remains and the incidental and foreign material MII be disposed of as
required by law. The cremated remains will be mechanically pulverized Into small pieces and placed Into a
designated container or um. CM add emalns generally am pulverized until no single fragment Is recognizable
as skeletal tissue.
OPENING OF CONTAINER
The crematory may only open the container losing the uncremated human minions in limited dreumslances, such
as to confirm Me kantdy of the deceased or to ensure that no material Is enclosed which night injure employees or
damage crematory property. If human remains am delivered In a container which Ia not suhable far dividends
such as a ceremonial or rental casket Me crematory will equle tlat the emalns be moved Into a whable
container before It accepts the wall The opening as container or the transfer or removal of remains will be
conducted before a witness and will be done In privacy, with dignity and respect
rMYT n FCEASED
Nomeof Daceased: L1Nvr1 G.-nn LZIS C hnOid Mmlel Gmbm: 5CPzzt&&A
Lem Knnn u c1me... 91
C4 r _ 1 ( ..''_IIv 12Q!2d OA l.locF G�k Finn yY 1232'1
Place of Death' EM fillk tt0`SJ21J9J
son: VA of Ago:gDDOE: l Daeor Deam:y•a, .AD Estimmutweight 14016S
Description acaakeucoMakren in wroth remain cool be delivered.
Comgamid CaNbaerd Box Wool Plywood SemeM Model a se8o0
PERSON IN CONTROL OF DISPOSIMON
(PereM(a)M wnhd oldtrpmltlm, Irma ONE Of be htloMrq)
I ant We are Me designated agent m Me tleceased insinuated in a will otwmen in mom easouted
pursuant In Public Health Law section 4201.
WW have no knowledge that the deceased executed a wined instrument pursuant to Pudk Health Law
aecron 4201 or a will containing d'eactbns form dkonsNon of he or her remains ant (CorrtnuMmrtrgal
Alher+ kanctc Schmid
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I ant we are Me ashism sl having primary ulster Public Heart law section 4201 and have Me night to audhome
ch"on d Me remains of Me daceasM. thi relationship to the dawesed is asbelieved
di tram the list 6elwv)
NumOenDesorifavern SOr)
A person MwgnMed in writing pursuant M Public Health Lax medion 4201 (3);
2. The surviving spatia;
2a.The survihng domestic p er;
3. Any surviving child eighteen yearn of age or cdm;
4. A surviving parent;
S. A surviving sibling eigMean years of age or older;
8. A Iawhilhy appointed guardian;
y. Any persons)eighteen years of age or older a prep M share In the seems and who Were combat in
relationship to the de dminch
8. A duly appointed fiduciary cf the estate:
D.A dose Mmld or relative who has eaeruded a wmlen "want pursuant M Public Health taw§4201(7);
10. A 010 fiscal officer Of a county or a public adminisbamr appointed pursuant M ome Sumgate's Chun
Procedure Act;
10a. Any Other prawn who is acting on behalf of the imposed! and who ham wmdd d a wntren staterni
pursuant M Public Heats tew§4201(T).
liati pLL THREE ofine Mkweld
.., asp�c¢ matter f �9 chest
Noehereby8ioac Mad the bodyofat eceuch does not wnleinavedOrdbaeery pad. power cell,
Autogveimplant, or pdetoreadeviceant time
any such materials were remomum in
MMeesecu Of this
AUMomatlon ham. Failure to remove Neve Ilams pries to cremation pry muX In hem m me wamalary and
creposal perwnnel.
.1i Me hereby,affirm that instructions have been given M (rmm.rerae.wrm.m.lderadir#10189 regarding
Me removal of any personal property or olherthirg of value which any down signing haloes On any family member of the
deceased wishes to preserve ftii M'mn gnbyiewcremamry 'is not responsible for
reemoval of parsonal items hi the contaimir or horn Me capture of the deceased persuaded Hems left In the container or
whom Me handles will be dMmye IX d by Me momentum ntum pro and cann be retrieved after cr "On.
-,SA NYa Mmbyaulhariae(remwm ) P' V C M to rnmam the
remains ofMe decaaaed.
FW.L o sPQ4moN
The person outhonored to receive Me Mmted amonwof Me deceased hen Me cremmory Is'.
Name'. Peter F rth Home PeargWill
Address: 11budememeet Nueensburv, New York 12804 _ Phrase(518)761- M3
The cremated remains ar dewesard will be disposed of as follows:
Realm t0 famiy M be decided
X he any raasmr Me parson named above does not take possecawn of Me memated remains,
fOY1�, 1 P C is suModuand M give lweaesspn of the remains to
same me delivery in pmson or by racisMred moil.
�t I,...+4- c.a ni Schmid
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_,"eNNe understand that tithe remains are rod daieretl wiMin 120 days of Damodar,
tovmre mine, P' U G may classes of ban remains In an inaMeveEle Mawr,
such as by scattering.
CRENAT ON CONTAMEMRN
(InAb10NE o11M kWwmpf
An um is be used as a answer far The cremated remains has been puXNmSd from
Bahr Funeral Home and Is diamond as follows:
Me understand Nat if the um is too small to hold Me entire cremaed remains, an additional rigid container may be uses
for delivery.
-OR-
-.JIj-- An am has not yet been pumowd. Me understand mad If es um a gardened or otherwise downbeat
le.i.wy�.il P Y C ab wid plain the Dameed remains kl a rigid temporary
contalnernecalivary.
This Aumrmaem Farm was prow0ed by Am w*wa-^"",
was xecoed at oiwamm Mimi B ber F H
pm.,nwnn earev, 11Lafavade Stre•_, Oueenaburv.New Yolk l2gM and is signed by has funbal wrier
as witness to its exelvdon.
WJe have rewWed a wmpleted osay of ban Authorization Fcr,n.
TM parsons) IdeMMed below Wan the pereoms) In combat of dispaalbon,who by signing this Authodization
Fomr, smells)to Ind accuracy and completeness of the irdannation contained in this Autndmmu nForm and
auth mosep)the foregoing.
Signed this a3 darer Trin .2e 42 DD .
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Funerzl Home Reg.gM131)
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