Elliott, Tamera Pine View Cemetery & Crematorium
Quaker Road
Queensburyl NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: N6 rugw _ _ _ RETURN TIME:DATE A TIME REMAINS ARRIVED AT CREMATORY: -IILITb ZrW hh..l
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
1,y��/.
KfL F10Cf NONE
.�
NAME: If1�.KA (, I CASE R / 7f/g
TYPE OF CONTAINER: FMW/ U:x/1 1�, TI� rtIN44K �:-�-
PLACE OF DEATH: GLF f4i r
ESTIMATED WEIGHT OF REMAINS E CONTAINER PIS- Lys
PLACED IN HOLD:
PLACED IN REFRIGERATION: 124(N
DATE OF CREMATION: -JHPIO d A�
TIME STARTED: �I:ItML� TIME COMPLETED: I' C6(111,AA�T�
PLACED IN RETORT: So At
MOVED: &aDM1� �"dn 11
RETORT A IN WHICH REMAINS WERE CREMATED: SppsL"H N11C
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOS SHALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
New Ywk Steel
//////---------�--IIIII OeO nmewwstlle
EWYORK Division of °"yIS10N°FCEnarrowed One
$TREOf sv.mglon>venue
Cemeteries
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Authorization for Cremation and Disposition
They Audiovisual Form must be W pl a and armed Prior to d011y or remains tar cre tiOn.
Dale:07106203o Number: -2i
Cremabry Name'.Pare YBw Cremakry
Address:21 soaker F , QU Mbury.NY l Must Prone:518-7454477
CREMATION ISA I IRREVERSIBLE AND FINAL PROCE98.
Cremation is mmetl out by plating Me remains of the dedasM arm Me wMaiion adding Me remainsiMo a aemalicn OOMm "OH
Ibeyaresu mteabinlen9enaataMfleme. TlwnM aM IIYMwIOlntlnxaG sari earuuma evsrytllMO eaaapanorw aOC mabL
winch are all tnRwill b0 M8 after cremation.
FoNOvnng cremation,Ne crematory will hike Membrane efforts to remove all of the reniaina and Omar material Mon Me uem n
chamber, but same minimal dust and wants will likely be left behind. The dromedary will mgaraW incWeMel and Health matenelhwn
the remains and me Incidental and foreign mmenal will be accused of as required Wow Thevmal remainsmilbeme mainly
Wlvenza Imo small stems and caused am a designate ¢nlanmorum. Lranutea rtmalne Benenlly an PUIWrIvduM100
shmas na0msnt Is modar el me sMi0 ltimue.
OPENING OF THE CONTAINER
The CremaNry may cry open the mntairer Immng the unSremated human remains in limited btumstanms,Pooh as m wnfimt to
identiryofthedea orbensurematmmaterial isencioedwichmght injureempbyeesordamagethevematONPmparry' N
human remains are refusand to a Promotional by not suitable for Oremallon such n ceremonial Oriental mks 1M
marory will assume that tb remains bar Howard two a suitable container before it accept the remains. The opening of a
coMeiMr of me transfer or removal of remains win be conducted before a whnase and will be done in larval win drenity and respel
X RnRCATMN OF OECEABEO
Noma Or DodwHM:Team nlbtl Marital status: Wtd,wJe�
Lest Known Pildrev:50 North SttM, Xudecn here NY 12839
Place of Dealt Goons Falls Hespnal
Sex'. ON OF Ati DOB: 1961 Dam of DendeIm07)DWOM EabnalBd weight: 175
DePdhpion a[awkevmnUlMr In wniM remains wio be delivered.
Florence Cremation Container, Plywood arso Corrugated Cardboard
PERSON IN CONTROL OF DISPWMOK
Marbi in summer Mdlspavlkm. madd ONE of me ta4msirgf
arrived are me catenated agent of this demesed resignation a"it an"Hen Instrument e[ewmtl damu into Public
Health Law aetlion 4201.
OR
1` will [Me
drandoforMeknowledge Mat me damn hat B ins andaea m e ment nsal present
ng Public Health w Law setlim 4Us Ora
Sc nbinin9 nd have tMMe d6pmicen r his or n remains and Have are Ma p d ofhaving pnewy under me io Xmlm law
ection azot and have me rgmroaumod¢e eemation anus renwmtolme aemeao]. Myloar relmion.nK a m.aemnad Is n
follows
Tamara Elliott
DOS Ill(Rev. M 20) Page t of 3
Authorization for Cremation and Disposition
Nummberber 3 rattieNwl
Number DesapM1m: AnYsuMving child elgMeen years of ape or War
1. A parson designated in wining Pascal b Public Hetlm Lax Secem 4201N):
2. The auMvirg ercum:
h The surviving domestic etcher:
1. My survival Child moment years of age or Older.
a. AruMmna parent.
5. Asumming aielmg ere reform years of Me or ones:
S. A all appointed Women
L My wrsong)egMeen years of age or Older entitled to snare in Me estate and who Coate cbeearn relamrnMp to the deceased:
B. Aduty eppalnted fiduciary of estate)
9. A cons,friend or relative who has exewled a millet slalementWrsuant to Public Heats Lew Section 4201(1):
10. A chief fiscal officer of a county or a public administrator VmnM pursuant Is Me 9urrcgam a Wum Pm UM Am
1Pa My Omer werem who is sMtg an beraff of the deceased and who has marmand a vmlMn snterrent pursuant to Pubic Health
Law Section 0201i71.
grager A/ LL THREE am@ follawbil
9F7 VWe hmaby affirm mat the body of me deceased deals per WMain a battery battery pack, power cell, radioactive implant,
or radioadve donee and met any such matwi ls"in lamoved prow to Me execution W this Remedial Form. Fall"to mmow
name Ihems plar to cremation may rxun In lumrM Me cumabry mind crwnelory WmannO.
FINle af0rm that mawcYpw have been given to rode Mlmer uxv n'enn
" regarding the removal of any Me al property a Omer Ming M value which any permn signing Wow or any family mummer a me
deceased wishes to lateral Pine View Cematory
is net responsible for the removal of persmal items fmm Me Carl or M1wn the real of Me deceased. Personal Ibma aft In Me
coCCnsaam+er Or with Me remains will be de V DytM cmWMM pmcamm and can met be Mrimi after cnmabon.
� 1prt MAN hereby authorities Pine View Cremecry owas"T
was
to cramaM Me remains ache deco .
(inkof OPTIONAL)
Mare Mreby aNbwrte the named Nneral director to provide for delivery to and cremation by an ambmab
remalory, If deemed necessary In the opinion of Me funerel dmredor,ants amend this brm to prig lde Me wmR name and
address of such abemaA smments.
FINAL DISPOSITION
The perwn aomadud M poll the cremated remains of Me deceased from Me Crematory Is:
Name: M 8. street Full Home
Address 82 Broadway, Fore Edward, NY 12828 phone. 518-747�
Me cm met trepminsyl� �4 III d�.�,pf ai
If for n
any masol�tlUMn�a piirsaan named`Move does not UM po9aemgn of Me cremalM Wishes.
Fine Vow Criminal a autlwized to ghre pm wa
m m
Ma remains to M.B.Kllmw Furoml Havre yyde4very
la.+'wi.mm4
In mason wby regitlerM mail. Temwe EllYNI
m�wsra
DOS-189V mov.Ooll Pull
Authorization for Cremation and Disposition
�yw ltg May Mideast
/\ 9 INie understand Mat it tors remains am M claimed wahin too eaysarpxnetian,
ptre New Commonly
m�.wn.,.syf
May ounces MMe ml.w in
an IneMNadle manrar,aanb es by xmedry.
CREMATION CONTMNEWRN
(Imtlal ONE of the blbwlng)
An um to he used as a container far Me cremmer sooner has Been purchased M1wn
and Is described as nIIW9.
Me understood that N tln um Is you enwl to Ma Me entire Amended romans, an mean y vil aaWlmr hoer to used M century.
aR
An um is nor M purchased me understand Mae 9 no Sm bpwNeeed As otMmlu pllNded
pin New Creaunry act pave Ve wwnektl rebound In
a rigid contrary container for delivery. ow«wcmrcn
This AUMONaatlan Form aria powder Ev Todd Kilmer was necuted at
6eww wrirwW
M B. Kilmer Funeral Home
sw
83&wdway. Fail EdwaN, NY 12026
n��ekvaswF
and is aigned Who Nneral dlrectw as witness b is exemmon
INIe bare cewived a completed mpy M this Authorization Form.
The Monsanto) identified benw inure Me parson(s) In control of destruction,who try signum this AUMonntlan Fasm,eXutp)
b Me accuracy and cormaimmess of the inlarmatlon contained in Idea AUMONUWn Form and auMorhe(s)Me frregahng.
Signed Mis fide day 0Jury mi , 2020 �In(-�-
Benjamin Efirm k
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