Coon, David M. Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: __S '' C RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: L I at b Y Yynt)
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
SflRAN P)(I.(O
NAME: l IkjQ 600 nCASE E II 113
TYPE OF CONTAINER: IIIWr" C 34ry
PLACE OF DEATH: ga III YlRehl
_I,
ESTIMATED WEIGHT OF REMAINS & CONTAINER 158 ILA' /ZDrlpr
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION: LIZAI ZD
TIME STARTED: 4iw Ar'I TIME COMPLETED: )Gw F41
PLACED IN RETORT: _ _ S.ILNPI MOVED: &00 /D'YgAn
RETORT D IN WHICH REMAINS WERE CREMATED:
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN AS HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SHALL RE RETUNED IN THE PERMANENT FILE OF THE CREMATOAY.
I
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NEWYORK Division of wwthmdddw
scan OF omsloxgFcederalMe
° Cemeteries
Tau yol
neutralvenereal
ADthoraahon for Cremation and Disposition
This AUM agm Form most M complaW antl signed prior b Millveryol remains for Cra 90n.
pale; 06/26/2020 Number:
Commodore Name:Pine View Cremetedum
s40Reu:51 Choker Road 0uwnsbury NY 12804 PMm (518) 745447/
CREIMT 19 AN IRREVERSIBLE AND FWLL PROCE80.
Cremation M camall WI by plaong Me rx m of to dxemud yM tM1e¢rtel Mining IM eflaiw into a oematlen cM will
May are subjMed to Insured MMard flame. The beat and Nma fall lnelmrab and mreume everything except bone and small
which m an Mat will eer left assay cremation.
Following memal the crematory all take reawnahie offend to remove all of the remama and Ova,material them be moral
chamber bid some minimal dust and residue oil likely be left behind The mandatory wiu separate Incidental and foreign emblem mom
tM insand Pelnader land MmignmatenalmllbediWp Ma$ mqui bby law. meuendaledremainsvnllb Rani lly
puwenumainto small piece¢and Owed into a designated coMairerw um. Crematednmalmgeroalhampuly Wuntilno
single small m racopnial as sl seftl lYslre,
OPENING OF THE CONTAINER
The vemelory may only open the demeanor holding IM women" Mmen remains In limited orcumYancee, such w to confirm IM
Nently W Me deceased or to ensure Pat no material is enGmed what might Irune empmytte V damage Me crematory property. N
In Omen rema bat sn dellWred In s camalnar who ich Is net so ftb for cremation sucm he mn MI or metal mM4 the
cmme will ,pain that Pe remains the moved Into a so liable rents r heft N accepts Pe neWm. TM Owning of
container or PB Mnafer or Removal W remmne yen N cM0.'bd before a widen¢a and Mil M ads in privaq,with dignity ant mspxt.
IDENnFICAnON OF MCE W
Name of Deceased: David M. Coon moth SbNd Monied
Len Known AWReee. 1506 County Rt 19, Granville, NY 12849
Plow of Deem.Glens Falls Hospital, 100 Perk Street, Glens Fells, NY 12801
sex. l9N OF Age 55 Dill O 0711984 I dl M52020 FaltmMe v4e4l[ 179
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IB 88etMdegmWdagentmPedBMYOd Magna ma MIIrvxnneninhmemexecutedpmauamto Pubic
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Me Mven0kmwledge MWI edawa executedawomaninstmmenfpumenlWPUNKHealth Law Sec4on9301 Ora
sell DYltelnlrg dlntlim¢fwthe dwpxltion of he "her remaine and IMe m IM peneni¢l hamp pnaTy, under Public Health Lew
Sxtion 0301 and Mve Pe rgMM eutMKe oeme0en dtM remain¢of Pe tle¢aeM. MyMur nbatbmbip tobw dscxeM 4 n
Mlowa:
David M. Coon
WS1oaeJ(Rev.0440) Pagel of
Authorization for Cremation and Disposition
Omar hem me IS bares)
Number'. 2 i snaption: Spouse
1. ASweden command in an" pmauant to Poor HyM ltw Seakn sgol(S);
2. The SuMWlg spouse;
N. The Surviving ceramic peMec
3. My summing
gcold eighteen years of age or dtler,
A
G A wmming sibling eighteen yasrs of ego or older;
8. A mainly appeintetl guaNun;
T. Any Paul engineer yeah of age Of OiderenlMM to share in be esob and who lsame dmbet in rel600mhip to the deue
8. Aduty andim ed fiauury N th
e Share;
r. Adeae Mend in MM"wM has exewlM a semen vase l pursuant to Public Heats law Section 4201(7);
10. A chief fiscal oRcet of a county or a public ad ran isbwar appointed comment W be Senegal Coum PmwMP MS
1es. Any Other person who b SON On Pence of be decauded and who me executed a wtllwn seemed pursueM W Name,HMXh
lies SeNon 0201(IF(.
feel Vol of me Whowry
mve hereby affirm that the body of be deceased does ram durable a battery, battery Seµ,[hand Pill. Mkvcil implant
IX retliaaµve device and that wry such m mmalm were crowd or"to be execution Mm a Mitsubishi Farm. Palms RInOW
Make eerm Poor W oglrlNon may mud N harm tome cnmwory and minimal paraonnel.
\(i LfAve affirm met insmcaens hwe been hall to Wendy all
regarding the renwvai N am Prwml kingdom or Other m vakm whilh any Prscn nil thaww acon Sandy memMr W me
demasedwarsa to features. Pine View Crematorium
N rest mnhhhsible Forth¢remMelUPoramal ttems kom me conbiMdIX hem me mmeim oftM tleceexd. PmomIWImalMlnan
corMlnefer van this remains will W dwtaoyad by the cnmwoon pracen tuna unna be removed hear model
M bnby,awharWa Pine View Crematorium
ro "S'7, .r
rem a the rwmlm W Me dwe .
fj=n pPNpr2AU
Mya hereby mWnmtu the mmM funeral dlrwWr W provide for Mail to and evil ray an night
meWry, ¢deemed nacwaary In May deal Mthe funeral a fern,anal W arena Mie form provide Me correct name and
"loco MwM albrrute mmmory.
Fall DISPOSITION
Tw person aumcmnd W npiva the wwnwe]remains oftled W hen Vn wemetayie:
Name:Singleton Sullivan comer combat Home
roams: 407 Bay Road, Oueensbury, NV 128U Phore: (518) 79S-0059
TM permbd Moslem M b MII[e aommol of"highest:
Return to family
0 he rry rem me pain named above Mw not take phsws IN N¢vemand nmuns,
Pine Yew Crematorium IS rmhemmd to Pine cone a
wrra
tra mrekaW Singleton Sullivan Potter Furterel Home MdelNery
InPomnorby regieahad mail. David M. Coon
m.sao�r
WSteful(Rm. 01R0) PMe2 cf3
Authorization for Cremation and Disposition
(y_W ur((a agbw+ml
�MYe rnMrelertl Met itmeremeln are mlreased within I"days gimina n,
Pine View Crematorium mmyd:pweol Me mruw In
Oiva,, a•eAm
an ineMevable manror,such has by euchring.
CREIMl10N COWMNEWRN
(Ietill ONE a am 10frev Hl
An urn to M laed as a Cimberar Or her aermW annual has been rychance]M1om
and IS deearibW as bIIPM'
LWe understand Nat title um Is W$realto hoe this sere aenxttl mmams, an sditmW ago wMainar mqW IW WaMMry.
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—
Rnum 'aMMMaCaMd. IM'euMeNW tl rimw :WWiaseduglwxbepr dW
Pine View Crematorium will place the uemmed mmalne In
�waww.a
a had temporary antairor for octa y.
This awmnn Form was travel by Wendy M. aull was esecuNd at
urdea
Singleton Sullivan Pattern Potter Faluneral Home
401 Bay Road Gueenabury NY 12804
Tore+mavw
and :agmd by Me Nneml dlretlorm xNassto its"caused
Me Mw rewivai a wmgekN wpYot Mq Authorization Form.
Tea peaanplldaMMM below Wantlw peraan(sl In[onbal oltllagnXlon,xTo py al0ntn01 Mn m a sRVNoriza For , Xest(sI
to the accuracy area compiaYnw MlM lnlarmatlon caMalrrW In llW Aul rintlon Form �auhorize(et Me haregaing.
Signal NN 2Bth cul June . ad 20
Khali A. Coon
1508 County Rt 17, Grernille, NY 12a49- -
All
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10461
Davie M. Coon
v.wa�a
COS-10WI(Rev. 041 Pa0eJ o'S