Washburn, Barry Allen Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: no KaBFIL RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: . 74I ID W&E An
NAME OF FUNERAL DIRECTOR OR REGRISTEREO RESIDENT DELIVERING REMAINS:
AVE KUmo
NAME: �RCl/ 47 ml) CASE N
TYPE OF CONTAINER: fl«.0 4" 4 la1�/4.,e� m +r .f
PLACE OF DEATH: TMr fLr it U' MU lIM> - ftal I
ESTIMATED WEIGHT OF REMAINS & CONTAINER / It tl&r
PLACED IN HOLM .y.
PLACED IN REFRIGERATION: 10,a
DATE OF CREMATION: 7k iZe
TIME STARTED: 11 IO TIME COMPLETED: I 'xr Pp,
PLACED IN RETORT: jhcAYI MOVED: Px Mt_I /Z:3cl1 P-0Ofi
RETORT # IN WHICH REMAINS WERE CREMATED: isKe IViC
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN " HOURS
FROM TIME OF ACCEPTED DELI VERY:
NOTE:THE CREMATION LOG SHALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
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NEW YORN plVlSlOfl Of DIVISIION OF CEME ES
STATEOF Clonme"w"
OPPORTUNIT) Cemeteries undent Arddlea
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Authorization for Cremation and Disposition
This AUMONntian Form must be cwnplwa and so nod From m delivery 0 remains roe amm"m.
Del Jul s.2020 Number: / 11
Chanel Name Pine Val Cremalwy
Address, 21 Quaker Road Ouaerall New York lYPM Phone. 516745-
CREMMN IS AN IRREVERSIBLE AND FINAL.MMUS.
Cre nis comae out by elan the remains;of the aeceasetl add me container holding Me remains into a ishmn chambes where
they are aubieeed to intense heat and flame. The Mat add m Maine will irelMnteand Consume everything bane add ora41,
which an all suit will M left abr emmaaan.
FoIWMng Crernation,the crematory will take reasolal~a to whi all Of the remains and When material from me Uematbn
chamber, but some minimal dust add residue will likely M left behind. The Gemalory vAI separele inaaeMel and forego maternal Von
Me remains and Mel reached and breiom material will par disposed of as required by law. The cremated remains will be me miolly
puNeraea Into Smell Peres and placed into a designated container or um. Cmmated remains generally are pulvarlvd until no
single IngmxR is ncagnlnble For Fall Ml
OPENING OF THE CONTNNER
The amatory may open the consu er belong Me unirtmated human remains In limited urwmslaum corn as to ranted the
identify of the dismissed cola ensure that no me@nel isentl0ea which Might ends employes ar aemegetM rs MM proneay. N
human remains are recoverttl in a conttlnerwMch Is not suml norcremvtlen such an November or menial aeeket,the
cromatory, will require that Mo remains M moved into a suitable customer bebre It accepts the remains. Theopenin ola
container arms monsfer or removal of remains will be mnaul belae a wAaa¢and will M domain primary.won dpmty and respect.
IVENT1RCA1MbNI OFDECEASED
Name of Deceazed:
9arry Allan WashMm chard Statue: Omvmm d
rut Known Mdrez¢: Pine St HudaOn Fall¢, New YorF 12&t9
Place of Cash The Pines at Glens Fells Center far Nursing and RM JgrdJon
seer: Elm 17F Age'62 Coe: 08-13-1957 ones,Of Deans:0741-2020 Eatmmated WeghL 150
Deeciption of confectioners ers or whm r,mn®na Mn M delivemW
Florence Casket, plywood conugated cardboard container.
PERSON IN CONTROL OF OSnoPO M1211
(Persm(a)In xrtmlMM podlr �GNE OIIM blbwmg)
emNJe ere me tle9yneletl again ofine deceased deWgneletl 'm a W.II or waXen inatrvnenlm¢uiled punuent to Public
Heats sew sedlm 4201.
-O
IrNir navenoknomeepo teal of aewaseeemo le add VO amawmempaemacim Pubbc Heeler Law section -uh or5
Sewmainng nd hale(w the disposition of his inner remans mains al are me persona)having paormry under Public Hearth Law
Section CROt and hm'e the right to authorize cremetron of 1M remains also,aaceaaee. MYlour relaxonMlpb Metleceveed b a9
b°PYs: Barry Allen Washburn
Page l of 3
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Authorization for Cremation and Disposition
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CREIW ON CONTANERNRN
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M um to the used as a condense for IM ummale0 remains has been pu"$W arm M. B. Kilmer FUMRI Head
and 18 downed as foNovis
INh YrAerslerM thad iHM um aIm I W and the"m GameadrMI61M,an additional age mrdainer"off reed far WNM
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j�M um N nd yet purclased mass undead aM that if no um is prom and or alM1exiu provided
Kind Yvw Crmmmay he phase the amended tensed in
a n9id terrigi small for delivi
This AVMorhdkon Form was pro'dant or Cleke C. KcngFa "a evec.red ad
rFva OYb/Nl
M. B. Kilmer Fumrel Hpme
139 Main St.50Wh Game Falls. New YOM 1211I3 Rwsx�N
and is sagned W the runnel director as wasess to b". tm
I]We have re¢md a cormin ed mpy of Audwdaadon Form.
laposition. ems of signing thlas
lkore Farm,
qs accuracy and cmanplebnlesss a We Information realned an tM1N Aueo MWO Form and authothrlm�s)am taepoiMg.Nel
sl9med this O3 yynf u 10-20 n
Brian waehhurn /Z/.✓/in U
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DOS-181(Rev. "20) PW 303