Baker, Wendy Jean Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: Oil[rg RETURN TIME:
DATE B TIME REMAINS ARRIVED AT CREMATORY: 6IUIm �:eefh
NAME OF FUNERAL DIRECTOR OR REORISTERED RESIDENT DELIVERING REMAINS:
FFSE4 BLRSKD
NAME: UEIIOM ^^Wfl? CASSER Ali I� I
TYPE OF CONTAINER: /WIf+1CYM ,( G�P'p1/ W- ./(� .Vy`e NF41FY X
PLACE OF DEATH: 4y 11(V !'y &j '1
ESTIMATED WEIGHT OF REMAINS 8 CONTAINER -f H18 1s
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION: Io47-Zo z a
TIME STARTED: ///4Q TIME COMPLETED:
PLACED IN RETORT: II MOVED:
RETORT R IN WHICH REMAINS WERE CREMATED: Fl.Jef '7 K 'SL
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG Sxnu BE RETAINED IN THE PERMANENT FILE of THE CREMATORY.
Authorization for Cremation and Disposition
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T Audmdaatmo Form mustM conflia dantl Ngm pmrm doll of remains mrpremadat.
Date: b ifbl m Number T I
Crematory Namew Pi a Vww Cremmm
Adder: Quaker Road, Ou bonsbury, New YOM 12S05 Fttens: f5llflir n
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation is earned Out by placing Me remains 0Me deceased and Me comeiner homing the remains Into a
cremation chamber where May are subjected intense heat and flame.The heat and Same will incinaram and
consume everything except bone ant motel,which am all Mat will be NR after cremation.
Fallowingcrttnation Me crematory will take reasonable efforts to remove an ofthe remains and other material fern
Me promotion chamber. bw some minimal dust and resitlue will likely,be kg behind The crematory will separate
incidental and foreign malenal from Me remains and the incidental and mmign Mideast w111 be dlsposed of as
required] by law. The cremated remains will be mechanically pulverized into small pieces and placed into a
designated container or um. Cmmaba remains generally am pull aizetl until no single fmymenf is rceopn'vable
as skeletal tissue.
OPENING OF CONTAINER
The uemalory may only open the container homing Me uncremated human remains In limited cawnutences, such
as to confirm the denti y of Me deceased or to ensure that no material he enclosed] which might iNure employees or
damage crematary propeb- N human mmairw am delivered in a p iner which te not suifehN%r emmagen
such in a varamenial a remal remain the crematory will reauiro that the
h ramaim be mwea imo a suhable
conducted
befor Rxwpts an remains. The opening mit consumer aor mefae s. ror removal of remains will be
contluRetl before a witness and will be done in privacy, with dignify and reaped,.
IOENTIEMATIONOFOECEABED 7
Name of Deceased: IA)enIL( lj4P/) nn (./VIu gMariet stams:
Lest Known Atldre/� (p,j ---((fQmil� pFt f1(.f,^,{ all 46 ld ll )rP .y
Place of Death rg /I? 50lk ('3SP M/ +
sea: oat PF Ape:�DOa:/O�O�/OF J� DIHea Deets:-T d -- Ewmame`Abigm:l _
Deacri�Con of ce>kabcontainer in which persons will will be dNyaed: �-"-'/- "-
Corrugated CWboW Sax with Plywood StamuM Modern 3MB
PERSON IN CONTROL OF DISPOSMON
(Pormn(s)Mmnhol aldsposNon, lnNelONEo/1MfNbwingf
I aml M are the designated agent of me tleceesed designated in a will of written Invmmarc executed
pumuant to Pudic Health Lew wooden 4201.
-OttR]1-
£ ,,
>rO N have no knavledge that the deceased emM a waben mabumellt purswmm Pubic Heats Law
tenon 4201 or will containing corrections ter Me Marce lon of his or her remains and
(Continued rwbaVM)
WRFI(IV J . f�
ntJ&1BB&IA (gw. 1'fltt) xma Ps1J9
l am/w am the Possess) having Priority under Public Health lawseRion601 and havetM1e rightto autlwnae transition
0f the remainscirthe deceased, My/pur¢YtlMf to W the deceased Is as ronaws:
(memi me lit hbw) S`Number 5 C¢ampton:
A person designated in writing pursuant to Public HeYM Law real a201 (3);
2. Thesurvivirg spouse;
U. The surviving domesim common
3. Any surviving Milli eighteen years of age or older;
A A surviving parent;
A survivhq cabling eigheen years of age or older
6. A Iawlully appointed guardian:
7. Any personas) eighteen years of age or older entitled W share in Me earth and who Were claws! In
relationship to the deceae¢d;
B. Aduly appointed fiduciary of Me estate,
9. Adore MendmMativewhohasexec awntenstefe pursu8MWPubliCHeMLew§6201M;
10. A chief fiscal officer of a county or a cubic administrator appointed pursuantto t" Sunpgme's Court
Procedure Act;
ICa.Any other person who is acing an behalfofthe deceased and who has executed a wntten siarerrant pursuant
to Public Health taw§e201(I).
Beal THREE of theJalk wan)
,0_-fe I/We hentles,affirm that the body of the deceased does me cormun a battery battery pack power call, radioactive
implant, or radioactive device and that are such severe Is were removed color to the execution of ttda Authoruatlon Form.
Were upremove these Item prbr m He eremitism y sent to wry to less 1.e crematory end proposal persemia
psi We hereby affirm the Instructions have been eve to o&w fvv s GssoRofl maI41W regarding Me
removal of any personal property or other thing of value which any person signing below or any family member of the deceased
wester to preserve. piw,wry ,i ) Pine Vim Cemetery is notresponsible for removal of personal
items from the container or"in the remains or the deceased.eersonal Perry hat he Me m itagmer or each the remains win be
destrawad by the cremation process and cannot be Measures Act cremation.
PSJ I/Ne hareby Mherire(m ,wr 4 Plne Vcew Cr¢mi[Ory mcremate the remains of
thedecemed.
FINAL D15PI)SInumn!
The person sutronzed to receive the oremafed remains of Me decemxd from Me aremetory is:
Name: Baker pummel Home Personnel
Address; 11 Lemonade Sheaf 0uienaWrv, New Yodt 12004 firms. (5101 7t1-0303
The Memated Panel of deceased will ber disposed of as fdbws:
Retum W family 0 be deeded
If for any reason Me pelmn natured above does not take possession of Me cremated remains.
n,tmonyneme) Piney Cremetary se authorized b give Possession of Me remove to
yurcgrenemmw Baker Funeral Home by del way
iin`pepelrson or by registered mail.
g dw yo =u1
,SB INJe untlemfand Mal if Me remains are 120 tlays of ttemetion,
ras+wm^�1 P' U Cremab may dispose of she remains in esinahievehlo menrer,
such as by scattering.
CREMATION CONTAINERNRN
tonal 0.NE oydw/dNwirod
_ An um m M used as a contavler far Me crematetl remains has been purchased from
g yef Forest Home and a chumnbed as follows:
WJe understand that IMe um is too email to hok Me enGrt cremated remains, an additional m;b container may be used
for tlegvery.
.OR-
22b_An um has not yet Men purchased IMp understand Mat if no um is purchased or otherwise provided
lameerywil PireV cremabry will place Me assures remains in a 4d temlprary
container for delivery.
This AulhorUation Form was provitled by Mrraan�n.�.t
Was exeaded on peww m.mme B k F Ho
LaleveM 5lreet O b N Y k 128M ark is signed by the funeral diresNr
as witness to its execution.
IANe have received a compleMd copy of Mis AUMorbatior Fomn.
The persons) idengned below Were the person(s) in control of EapesNlan, who by signing this Authorization
Form, aMest(s) to Me accuracy and completeness of the information contained in this Autharaallon Form and
authenticate)the foregoing.
gprred this 25 days 2m� .
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Funeral Home Reg.Al130
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