Graves Jr., Gordon N. Pine View Cemetery & Crematorium
Quaker Road
Queensburyl NY 12804
(518) 745-4477 or (518) 745-4476
FUNERALHOME: AR(ApfrfE RETURN TIME: ,y
DATE S TIME REMAINS ARRIVED AT CREMATORY: 7IL I ID 7i QA
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS: -
oA11, A%4Yy)&9
NAME: Gw4W CFAYEP CASE 0 IT)
TYPE OF CONTAINER: Nfu I1f dJ A �IIF ( }(:NJ
PLACE OF DEATH: � YpI W POL `iFF 11 I J IFp'N
ESTIMATED WEIGHT OF REMAINS b CONTAINER PTO IF
PLACED IN HULOI
PLACED IN REFRIGERATION:
DATE OF CREMATION: 7hIV
TIME STARTED: 1);P FYI TIME COMPLETED: III S�/r
PLACED IN RETORT: 114ft MOVED: /I
RETORT % IN WHICH REMAINS WERE CREMATED: Sal FaEL All'
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN " HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE THE CREMATION LOG SHALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
mi k Sal
NEW FORK DewmrmMwslw
STATE OF Division of OMSIOH OF CEMETERIES
OPPORTVXITC Cemeteries 99Vistva° ....e
Newt.NY 1323bM1
Telep w(SWHAa326
Authorization for Cremation and Disposition
TIN is A uthoRaOw Form must be cpmpleMd a no signed Prmr to delivery Of Named na Our cr ton.
D.M: 0710612020 Numb,,, 75
Crematory Name: Pine View Creftinatory
Address: Quaker Rd., QWendbury NY 128N Phase. 610 )IK A47)
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
CMem is limed out by plating the remains at be dewantl and this container holding tlb remains into a cremation MmiN wMre
they aresulNeded b intense treat and name. Tha ham and Rome will mclreraa and c ume wary ing eawlN bow add nwY4
which wax 211 mat will pe left after cremellor.
Following cremation, the crematory will take removable efforts to remove all of the remeins and other material hoar the cremmore
chamber,but Some minimal dust and residue will likely be left behind. TM uamelary MII separate incidenral a"loreign maNdal M1om
He remains and theineidenml and mrelgo mansial will be diwo¢ed of as required by law. The cremated remains MIl be mechusu ly
purerued ido small call and placed Into a designated consumer or um. CwnaWp im ganenlly are pulwdsed unbl no
BInal*fragment m recagnluble ae ske lbwue.
OPENING OF THE CONTAINER
The Gematory may only own the rvnlairer hddirg the unCRmaMd human remains in limited dcumaUnaB Such as m confirm the
carry of the becumed or to ensure that no moral sawthembf which might Injure employee¢or damage He wamatory pronvrly. If
human remains an deliver" in a withdrawal is not suitable fwcremabon such as ceremonial or renal casket,the
worato will rwuin that the handles be cow" Into a miteble c inerbe M ITremwhe SCCSM the tl . Topeningda
ry roomerorthetrensferarrenewalofremain.wigmconduu metreawibe andwllmdoeeinpnlwy windgndyandreopen.
I9EM F CATION OF DEOEASED
Name of Dexawd. Gordon N. Gmws, Jr. Mantal shows. Married
Last Rnawn Author. 14 Big Hollow Road lake George, NY 12845
Raw of I th , 14 Big Hollow Road Lake George, NY 12845
Sax. ® M OF Age: 80 DOB: 11/911939 Data Dean: 07103QO20 Esbmat"wegM: 150
Central do keuwdaiwr in wham remains wu as defruered.
New England Crernation-deluxe Container
PERSON IN CONTROL OF DISPOSITION
derwhim) in wool ddiapcsimn. initial ONE dtha/dbwing)
I emnve ere the dwgwbwI agent of the deC aged desgnat"in a will or western Instrument executed rural m Public
Health law Sedan 4201.
-OR-
M1Ne nave no kmwtedge bat the dare executed a wrien instrumentmmuem in Public Health Law Samoan 4201 Ora
IWO ing dlndicry far be dlepbatiM d Ma or her remains and lMV are the wreamst having pul under Public Health law
Sector 4201 and have the ngMw auNonm aemdion of the remains of be deremed. WMur miationehlp toted Mceased N ea
fdlm
Gordon N. Graved, Jr.
DO5 1898 1(Rev, rul Page l of
Authorlution for Cremation and Disposition
pnsertymm rM Mf DerowJ
uurrner; 2 oescrlpt'wn Sumvinto Spolike
1.0. AMaMason
designated inwnOng pursuant to Public Heah law Setl 4201(3):
B syue
U. iM monad domestic garner;
3. MYsuMviig &IN eighteen years M age or dtler;
4. A surviving pares,
S. A word Up soling alghteen years Of age or olden
6. A lawfully appointed a um dun;
L MY screams)eahmen Years of age or older entitled to She re In the estate and who was re doe t l n relatonsbip to MCK¢eeM;
8. A duty appointed fiduciary of Me elide;
8. Atlaw M1ierq or deal Who has executed a womr,snbnent pursuant to Pudic mean law SMion 4201(7)
10. ACoist fiscal officer of a County or a Publics Nonlinear appointed pursuant to the Sunogate'a Court PrttMure Ad;
10a. My Orman person who le MAIN an MMM Of the disclosed and who has executed a whom statement dunked W Public Heed,
Law Sal pL
moffigull ALL Thful OF the Reining)
_s-L unlike hereby Mirm Mat the body of Me deceased does not comam a battery, baory peck, parer w0, radlwdive Implied,
or awassuchis deem am than any Such materials were removed morto Me execution INMis AU oa aWn Farm. Falluntonmme
these Mies prior to cnmeeon easy result in harm to Me cnrmtory em crwfutary parson ll.
IAil not that inswckins have been given M David Meoander
regembq the removal aany personal property or other hung a value which any person signing below or any family memMr a Me
deceased wishes to preserve. Pine View Crematory
is not comparable for Me removal of personal terra frem Me conminerofrom the remains of the deceased. Panonal lMrrts left in the
co=ineror Wldl the member will M destmyaa Md<cromalon pr«des and cannot be rmrmead stet cremation.
4 Me hereby:mhortn Pine Vier Crematory
A,w'ire" to cremes the remains of me d "sag.
p=i Carl
Ion hereby aumori:e the named funeral Efrecnrto provide for daliveay,to and cremamm by 80 seemed,
soy, If deemed Nuclei In the opinion 0the funeral director. and to amend this to farm provide Me corns name and
rides of arch anarni m managers.
Fill DISPOSITION
The pardon aMadnd to receive the aemalud mature of the deceased fmm the churl
Name:Alexander-Baker Funeral Home, David Marylander
Address: 38D9 Mein Street, Warrensburg, NY 12885 Prmo (518) 82&2085
They mat remalrs of de2ned MII be disposed of as folio"
Return to family
If far arty Name the person named above doe; not take pcssessucn of the cremated remains,
Pine View Crematory m amhmne to give poseawma
"'W"i
Me mmmnas MexanCer-Baker Funeral Home by hall
M person a W rpia mad ✓�.e.<.e•+•x Gortlor N. Guavas, Jr.
p�ww..m
D Ilk rf IRuu. OORO) Page 2 a
Authoriution for Cremation and Disposition
unga the radio g)
Aft un mWa Mat ante real are rM claim whin 120 days Or uemaeon.
Pine Uew�Crpmatory may dispose mine remains In
an ineervabk manner.such as by eat dN oT+wt
CREMA ONCE
(�tgYE o/tlp lddwM�
A AS um to de used as a container ran the vie tO remains has l der oumnasee mom uiexhandder-Baker Funeral
and is eocebace as folio"
lead material that If Me um is Lo emau to hole Me snare annual rommays. an Addition.l nand containerwise he we err dYMry.
DR-
--sit—b An urn is nor yet purchased lMe uneemMnd that if no um 'a pared t or Mhennae pmaleSe
Pine Vi Crenat will place this xrnated reme'me in
a and Mmilmary condole,he dewery.
The AufMNzaaon Force was Provided by Dayirl Alexantler was wedded at
Alexander-Baker Funeral Home
MOO Main Street,War enabuM, NV 12W5
and is Signed by the funeral header as withers to its eaeat'ronx+navw
MASS have,meeivad a Cloadded Assay of this AUM zNm Fame.
The mmonpl Iced below Won the I»manp) In control of dithemition,who by signing this AuNonzation Farm, awl
To to accuracy and emn enma oa the Information contained in this AWhwandon Form and Appraisal al printing.
abroad MIS 501 day of July ,Me 20
Jenny Graves
14 Big Hollow Read, Lake George NV 12a45
WITNESS:
David Alexander
a..m+nmsheae.wt
10034
Gladden N. Graves, Jr.
Ira..ao.�e
DM1 Ba&f(Rev. WN) Papas;d 3