Brooks, Rose Pine View Cemetery 8: Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: At tjA NEQ RETURN TIME:
DATE S TIME REMAINS ARRIVED AT CREMATORY: W5I0 /0 %Mll
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
MYDE Kv,HC4
NAME: CASE IS 7,T/4I
TYPE OF CONTAINER: y� 6rt(Sp/A
PLACE OF DEATH: IS (DIWr ftrw', iMt �a.lG 1_/ 1I 17yt
ESTIMATED WEIGHT OF REMAINS 8 CONTAINER to LLf
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION: V)a ID
TIME STARTED: IO;$(I All TIME COMPLETED: /' �/LI'.20 Pm a�7
PLACED IN RETORT: I6W AQ MOVED: q:W�T�/DIN1I1[Mr
RETORTS IN WHICH REMAINS WERE CREMATED: ✓MWSN I;bIA.
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORETHAN 48 HOURS 11r
FROM TIME OF ACCEPTED DELIVERY:
NOTE:THE CREMATION LOG SHALL RE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
DN OF CEMm IW
EWVORK Division of DMSN1on, Nin"ipull
HOOM
°'�"^" TY Cemeteries hlingu ...
Wa ancielft4i
Authorization for Cremation and Disposition
This arMw6aXon Form must led complab0 and atoned Motto anwry a tame-lane tar ammenon.
Date:Lune 26, MO Number 7"1�
crematm Name:PmV cmhnry
Md. Quaker Rd. Crystal, NY 12504 From 51b7454477
CREMATION 18 All IRREVERSIBLE MD FINAL PROCESS.
Cannelton t ime out Ey pletlng the remains a Me demawd age me container holding the remeiM InW actin Moreton where
they are subjected mmminse Mat and tame. The Mal age Um wall InciMH age comuma"Da ;ng damage bore end media
which an at I Met will M NS afar cmmal on.
Follimuft cremation, the vandal will all rea9Netk eabrbto remove all there remains end other material hum the cremation
chamber, but some minimal dust and actual txay we ten award. The rnmetgy will Famous coal and roreien maeal Than
Me ramalre and the incdental add Map maenad Or Mdispcaed Was reauiM bylaw The gemmed remains will be meUenlmlly
pumansomm small plows and piateed lac a deSsimed mnsumemrum, Cmm emaamgenerallyanpuMdW undim
single 1ragmanl Is recognbable naMlaal hNue.
OPEN XO OF THE CONTAINER
The crmmemry may only open Me container ain holing Me unaemalN human remains In IImIW unsumslmwe, such as To confirm Me
identity of thedeay eyed or to ensure Nat an memdal is women which mgninjum emprome9 or damage Me aemmcry panel lr
human remains am dtllwmd In a wnelmr which 4 rem suitable her cnmabon wcM1 as canmonhl wren al wekm.Ne
oratory will rail Nat this mmlm be movM Ina a suas his container Mfore itaccepe Na remelm. The oWndng of e
container or the humeri removal cf mmaintwill hewnduced babre a¢1Meae and wall be done in Wlmuor wiN dignM age resmm
DIENTIFICATKIN OF EBBED
Name of naceawal Rw Bnccb Manta small
Last Known Mdr 15 cumer St FM EWmd.NV IMS
Pled of Owed lS cider SLMay Erward, NY 12M
Sure QM IMF Agi Dog. 04-05-1953 Oaeol0th1 11,2a20 Esmnaed N§reM 180
Overmatch of dakaYmnmimr In which remain will M dawn.
Corrugated cremation container pine and cardboard
PERSON M CONTROL OF DISPOSITION
(Peraw(a)In[wna a andmol Cn.Mita ONE urge Mbwngl
I whal eve The sweetened agent of to dawaM dmgme] in a will or will instance awarded puswM to M is
Heel law Some,4201.
-OR-
LNb new no kmwbrtc Mm Me dswadd Damaged a xiMwi imWm ad mrNenlm Public Health law SxMn Q01 ore
vdl dntamlig dlnctlens br Me Mari of his d her remains add Ym am Me wredMsl NOW phoney under Pub lc Health Law
Section 4201 and have Na din bBUNoNe aemai of the remainsa Me dearall eyour medarchlp by MD deceased Is ale
ell a
Rose Brooks
DO Tls hf(Rev. 044No) Page I a]
Authorization for Cremation and Disposition
Num�Numb hmmlMNal EBbwf
r -S
1. Apereon dBQnO In wrAng pureuam to PWic Hmmm love Sev9on Al
2. The surviving spouse;
L. The server no domestic wM+r.
3. My surbNng Old a,igB n years of ape or odder;
a. Amorning prevent'.
I ABurcinng sibling eighteen pare of adds or Older;
miAny gdmna eighteen"am
m+cenOlder ennnMmenere in ins estate arm wno iv+m dined in reladonMmm Me m"ase1;
0. A duly appointed fdupery M the eseam;
S. A does Mind or relative who has executed when statement pursuant to Punllc Neagh lave Section 421I
10. A OW final afar of a county Or a public administrator secured Wnuvil m Me Sur]ems Coud Procedure Ad,
10a. My cMtt pweon who is whang on behalf of Me ceceamd and who has me a wlben statement cu based m Public N++M
Lax Section MNIm1.
( ALL THREE mad fdbafy)
IMb whoor ammi MI the body of Me dominant does not contain a hathery bade s pad. Power mu. roddent ImPl.d,
or ra]Ioadive ntavYR+nd Ma[erry wGl matanels ware mmoved phwm Me e✓aMon WNiO AUMaebatlon Form. Fellunm Mnovu
Memo items prlwm emmOm my result In harm mica CMMa Band cr tOq "mmnel.
yIMb efirtn tM11ns1iu liorehaw GOen givanm Nyle l4lmer
ragariing Me removal W any pabamal poea or otlKK MMO of value which any ceieni upnirg bMW:or any fenny tap rMMe
ds®aaed wanes b promo. Pine Vow Chemistry
is net succeeds for Me mandi of pOrecwl items from themnuirw atom Me"maim of the deaassd Personal Name IM In Mo
Z+r or with Me"maim wall Me m" d 4Me enmatlon pracNa and inn not to nMevab d ar cnmetlon
M Mnby auWaN Pine Ynw Cntrol tuna
m a"team dte"mains W Me wdaaaad.
(menu OPTIONAL)
IMe Mnlm auMorva Me named mnMl danemr m p" $any dMlvsry b and cnmanon by an abmma
mamry. N dammed no" " mice dra lob 0 to mnenl didctor,and m amend this mesh to Provide Me mead name and
addMa Of such aabmab cnmemry.
FMAL DISPOWITION
Tnepai beam Me cie hmnaam M tic demanded form W nem=m he.
Name: M B. Kilmer Fi niM Nome
Adore": V BmentroY FM Ed M, NY 12WN Pr. te. 51 747KcfO
TheeQmmM n m of dema"d WWII be dep.Wd Wes WI.
Iffor any re00an the"such named im6 Meg hwl mFe po90 ion of Me MmN Moran,
Pine View Cremmory Ida holae]W I model of
the remeMB m M.O. MI FUM l HMO m�mWw b/Mwhe
weed
in comes or by maintained mad x...ux...Rm Oddw
DOM109al diam, i nswx Page a
Authoriution for Cremation and Disposition
ff Me rairxNnpl
INJa understand mar if me,remains are not aeimea vnpdn 120aayeaCRmarlcn.
Pis,show Carotin may anowas or Me symbol in
numemcnnwn
anuMnemi manner.Such as by sWbanne.
CREMATION CONTAINOMRN
fmiddd ONEc/Ma1h Hainpf
Pn um m b assed as a barrel M Man vpnel remNM has been purchal Son
and is desi say Sol
li understand Met If Me um is too Wall to had to Sol crMlaW Wall an a fthonal n®m Wrrlassommy Ee malhe delivMY.
-OR-
pnumanmystpuravua. IMwunderstand Maitwum ApuOa moMMnve PmW
Rre YimvCmmeYry will prep the cremated n mains In
a rgid Whaley mMaineV blhBry m�eenvwm
This AUManse40n Farm wn prwa✓1 by Kylo Karl was execute] at
M B Moat Funeral Harr nrmma ^eT
nur.r.rrwrr„.r
82 Brwdway Fan ray"m NY 1382E
and is siprctl by the Nnerel dal as wimeu to bar execution
rw`+ewmr
INJa have received a compared copy of his AUMoriors0'N Form.
The gnonfsl lderrBBed below ILare Ma peraonla)In control of d cep ishloq who by dead ny May AUMcAmmorr Farm,aneeys)
to the eccurmy and complebness of des IMonnal comfolned In MIS AUMoriti Form and ached IMe forpol mg.
Slemed Mls24VI day of June . 2820
` 1niv w L Oc4ia �C pYJ 0
15`"' "Tenor pvt- 4J� don -Cn rJY i?R-�a
M NEaa:
Kyle former I
rlWvaw/v4 aane�rr
IOfiW
Rand BroakB
prrwoa�y
OOs deal Tmv tMRO) Ppe]d3