Pullen, Jane B. Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-�4477 or (518) 745-4476
FUNERAL HOME: [r__„ __ RETURN TIME:
DATE A TIME REMAINS ARRIVED AT CREMATORY: blttlSO 29ogh
NAME OF FUNERAL DIRECTOR OR REGRISTEREO RESIDENT DELIVERING REMAINS:
HARK OFS LM FE
NAME: QRVE P11 g CASE S 74C
TYPE OF CONTAmEPo V e2wri' pocr 6*4t.
PLACE OF DEATH: LL.r MY lb>plhl
ESTIMATED WEIGHT OF REMAINS 6 CONTAINER_ AT y 7 / /A5 Cs le)
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION: li'.7�/- fore,
TIME STARTED: zf- TIME COMPLETED:�1.
PLACED IN RETORT: 7� MOVED: E1 — f3zpY
RETORT# IN WHICH REMAINS WERE CREMATED: �..PiT aM3er fbP
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN AS HOURS
FROM TIME OF ACCEPTED DELIVERY;
NOTE THE CREMATION LOG SHALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
d Sure
°eWNnM MEM11
NEWYORK Division of LRVISIDNW;CFMUEERIM
STATFOf o IN Fla
OM
°"" "" Cemeteries 'nA2imuni
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Authorimflon for Cremation and Disposition
TNb AYtl atl Farm noel per completed and signed Prior to cadavers of remains for cremation.
°ale. 06119/ 020 Number.
Cnmabry Name:Pirle Uew CR atory
pedrees:Guaker Roatl Dueensemy NY 12804 Phaver (518) 74 76
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Gem ddm Is comes an by pacing the remains of the deuewO and tls wnlawr noldelg Me remalm into m mdan WmOerMve
May ere sugecled mintense heal and name The neat eM Nine MB lzlmreW also c um avarylMne aanpf Eons and nNYI.
wxkM1 Any all bon MIS be NN after crenanon.
Falovnng momanon,die crematory will Mks re9sonaae efforts to remme all of are remains and them caul more the cremation
chamber, but some minimal dust and norm MII III the Jett behind. The crememry as l separate material and br ign material form
the remain and me lnclsenul and lomlgn material bon be dl¢ryeM Was rtyulred bylaw The msmetN romainsw I de nrec^enkally
puNed Into small piema and DameImo a desgnated¢mlaim or with Cremebdnmelnsgeborellyanpuiv Munalm
single fngmem I$ recoenlaabN as sahmal tlnue.
OPENING OF THE CONTAINER
The uemarory may half open the rnnlamer Iroldmp the unome human remains Inlimited tiumsbnma.auto alto confirm the
wenty of the demas arm ensure that no malarial is eWA "Sol might injure employees or damage to crommory pmFMy. N
human remains are Mlvend In a conbinM"kn A net suitable for metabolism such as mrM for meal wiM the
crenWory will nauln MN Ma remalre be movetl Ieo a vuNW conNlmr Mdra Nauap4 Me ralmim. The opening ola
nnuiner some wnslm or etmoval W remains an m oarkaake bekre a wtmaa.m con a sane im prvahY. wan dgnty sine r.yw.
IDENTIFICATION OF DECFABED
Name of Demased. Jane B. pullen Ltelul swam: Discounted
Last Nrwwm P4detM:58 Fan Large, Dueensbury, NY 12804
pram dSDnM;Glens Fells Hospital, 100 PadL Street, Glens Falb, NY 12801
Son: OM ® F Age: 67 DO6: ON1111953 DinwN ON11112020 IWhnMed WegM: lov?
DeecdpYon of meketkseeme in Orion m mne wRbbArerM.
��1C 1,6�.n—} � CGAilt
I ft'lo x CON1RDL OF DISPOSI
(Pn+mfel f^cvnbWWWs ,mayor DNE W Ma mntwag)
I YMVe aw The deegnsled agent of the dewnat stagnWed In a will m'MNn Instrument eaamded pu OM to Public
H mI sector 43gi.
on-
e have no krwweedge that Me daNNNI necuM a while m mstrument puNlantto Public Re6M Law section 4201 or a
w"J n430 aM�euern0htbamieMlMovchnmatbdM@mmanl ortneaeMboaSM. YyMurn U Mnlproue'a.•...di.tee
bless:
Jane B. Pullen
asi
DOS-18964 IRev. Oar Page 1 of 3
AtOorintion for Cremation and Disposition
(heal Me Nat 08bw)
Numcar: 3 Oeeagebn Cgiwahter
1. A pension designated in warmp punuamm Pudk HaMN IAr58 Yon410113y,
3. The swung argues;
L. TM mwm 00mestic Wnner,
3. Any SuriiWq Mlm elgmeen yeas of age or dear,
A AauMnrq parses.
R AsurmbigW irq egMcen yen of age or older,
8. A Marshy appoiMea Meanings;
T. Any presents)egmeen years M no or drier entitled b eMre in Ce agree and Moisten down inMI hip m Me drx l
B. A duly appointed hauuery of Me®tees
F. A Ggw Mind or remarks she has executed a embers smemeM punuaM m Panic Heats law seems 0301(7).
10. AOW fiarel otNrer of a wumy or a public administrator sppoMed passage to Me Sumpale'a Court PrrcMus M;
Its. My other person wT01s ativq on theKM M Me aewwN and MO has exeatetl a waden Smtemem pleasant b Pidlc Health
Ling SMicn 4201(7).
ALL TMEEdtlre Mbwup)
tMN Mashy emmm Met Me Esay athe Missouri pew set modest ES Wry. MMry peak, power said, redlwtliro imp4m.
digestive MNss and Mel any III mmeMb ware staved tomr m the assessment of this Autlsrin Form. FYlua to nmwe
�t1e�Ma/,1la�nrs prior m mmalbn may Sault In hem to has me wed csmatwy grmsal.
/ IyA"/ Me atMm Met mslruc1ions hay$then 9men m WWeenndyI Bulicll
�+fM\IeJed�mg Me remonl of any personal pgerty or super Meng W views whkh any Ferson aynfi g pew or eM1arNY rmnM Of Me
d 8a wanes to prearve. Pine Vim Cremnathory
41g1 reaanaable fur Me remgval Mcengnal hemahrm tW wm.inM o�M1pntle nmairse eats Winded. Pmoml Wms Mat lnt
or a)with Me remains wall W destroyed In ma rnmmbn process ape wooed Mmaaied after cremation.
W�.ey amMRa Fine VimCrematory
Tro�rxw msnm.mtW raWma gf me aecawae.
tndal OPTIONAL)
Its harbor authome,the named fumrel III im rb strongly bar delivery t0 and cmmatlon W an aNmW
cmr IIf dwm mrommary In Me opinion W per Iunenl Meadow,and mamand this form to provide the comet name and
Mdau of such a"MaW someday.
FINAL DIS 80.9 N T1O
Ts person NMhzedto ramie Me aemaW ranging W Me@sewN ham the mmBlmyie'.
Name:Singleton Sullivan Potter Funeral Home
Mdrees; 407 Bey Road, Quee tsbury NY 12004 pW (518) Tg& q
TM csmebdr im a a awurd pit be aapgaed a Me Mien:
Return to family
XM any reason Me area nmN alone army rest take pxurwion othill vwmMd romaim,
Pine Uew Cremamry b authodaed to give pmwwlon of
the designs to Singleton Sullivan POVer Funeral Home by maser
m..ax..nr=ar
In pereanorby,repiemeM real. Jerle B. fpulbn
ar+g�a
D iew(part MUNI Psi as
Authorization for Cremation and Disposition
( awwnal
Irwe mn rcaw mm..n.m mea.irmiawmin lza days awem.ucn
Pine View Crematory may aepom ells mmNna In
os .tl
an IrmdnabN m.nm.,snd, as by easMdrw.
CRENIAnONCOWAINERNRN
( bad(yVEapmloeowwng)
An um W be used as a contains br the vamaled well has been purchased!Man
and is anse ibed as Mlmvs:
--J/gifif�ee//essential led x the um Is 1W smell at had the care intended remains,an vA1M+a rod contends nary M used M del ey
um W not M Wmnx Noe understand met RM vn W Michael mOVreMaa Weaen
Pine View Crematory will ptaw the cremated remamsic
a t®id temporary Wn0IfM 1IXd¢Iwry. �• Gmen
This Autherna n form was pmridad by Welly M. Bull was executed at
uma
Singleton Sullivan Potler Funeral Homo
w..ore...e=w
40i Beta Rued �ueenabury NV 12rN14
al is signed by Me Nnaml dirtdar as whites W M enoulion�amN
Me have received a mmgetM¢qy 0b i$AUMartrtllon Form.
TM pamnllftnN lbw Wan Me perdamas) In coma of diep n.who by staining ante RUMmhWm Fwm,enrtls)
b all accemy and wnpbbnms a Me Inlomutlon correlated In thin Autlrwhatbn Form and auYwN%s)are fwep M
intermediate ift days June 10 20 Jeanine R . //�� _
eppenhagen C( I,KLd
m.asmmeww. /
4 FamiWWn Place Ouaensbury, NV 12W&
inshis
byeeirlainki
All
v w++
Akhap
WIINE58:
Wendy M. WHO 1wT\`
a+�+am+.rwd.r*werwro
10441
Jane B. Pullen
pry✓esr
p l 59al(Rev. 0a2J) PW 3a3