Walden, Robert Eugene Pine View Cemetery & Crematorium
Quaker Road
Queensburyl NY 12804
(518) 745-4477 or (518) 745.4476
FUNERAL HOME: ALE{WOEO RETURN TIME:
DATE S TIME REMAINS ARRIVED AT CREMATORY: II2IID ILmPh
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
at* ADEgIU&4
NAME: Loator WA,LOU) CASE -ISl
TYPE OF CONTAINER: VUJ 1 kta Al( U Amatc
PLACE OF DEATH: IDL Rit Strap 1 AF GOfM1 17ID111
ESTIMATED WEIGHT OF REMAINS 8 CONTAINER ILO [46 LE yr
PLACED IN HOLD: y1
PLACED IN REFRIGERATION: iz.m ql 1
DATE OF CREMATION: 7 A /YO
TIME STARTE(h 1''I1SAM TIME COMPLETW: (D%�
PLACED IN RETORT: _ )o AYI MOVED: ftzoAo IT�rF/If,ZJ�
RETORT 0 IN WHICH REMAINS WERE CREMATED: 7Miwi. pez
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 46 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SHALL BE RETAINED IN THE PERMANENT FILE OF HE CREMATORY.
York
SEWYORK i)IVISIOR Of D.wmn.ntnrstan
STRTEOf DIVISION OF CEMETERIES
OwOPiVNIiY Om rm
Cemeteries 99
Wcommerwelashington Avenue
ielp er Ou siwis
9oxMGo+
Authorization for Cremation and Disposition
TMe AUMoriaal Farm must be completed and signed prior W delivery Of remains far cramation.
Rafe: 07102 020 Number
CRmalory Name: Pine View Ghana
Addrev: 21 Quaker Rd. Qijbignall NY UlXbi P1me: 716
CREMATION IB AN IRREVERSIBLE AND FINAL PROCESS.
Cremation as carved but by places the re iim Of the Midwest ant me whatever hall tl1e remains iMo a uemat'ron chamber Mwre
they ere subareas W intense heal and ranks The heat and flame will incinmb and wnaul everything eaup done and mql.
Which am ell met will be IBM1 After cremation.
Fallowlrg uemetion, the QW1Hwry will lake masomme eflohato remove all of the remains and other makdal tram me aemmon
Member bin some minimal due and mercury WII likely m left beHmd. The crematory wall separate m rdenbl eM or member lion
nwmmaiinantme 'maaenWlandforeignmaledalwmbedisw Mwwviwbylaw. The cmmated remains will br meoranicaor
polvedaedimo amau pews ant cMWd Mm a designated commands um. Crememdmmainswnemnyarewlvedz uMilm
single fragment M mcogmwMe as akeleml tissue.
OPENING OF THE CONTAINER
The uematay,may only open he container trolding he un<rarma d human remains In limited uwmslaime. such as to wMum the
Nei Mthe dewbsll Of ensure that no real andosed wrich might mute employees"damage me cremarory prapem. N
human mmalm are delivered ha mmahar which Is net suitable for cmmadon such as pare ial or real casket, him
Mabry will require May re the mains be moved into a suitable communist bef Itw ore acpM me remains. The opening Ma
computer arms transfer Drummond M remains will day wnduWH prom awmew and van be done In anyway,with diguty and respect.
IDENTFIOATION OF DECEASED
Name of Dweared: Robert Eugene Walden Mandel thand; Divorced
Last Nmmr Address'. 1M Maple Street, Glans Falls, NY 12MI
Piece of Death: . 102 Park Sheet, Glens Falls, NY 12801
Bra: ®M OF Age: R4 DOe'. 04/18I1936 DebrofDal 07I0112020 Estimated Weight: 160
Desonption of metatarsal In which remains will m delivered.
New England Cremation deluxe mandainer
PERSON IN CONTROL OF D 9POSMON
(Pe (s)In wnlMMMswvlgn, infalO EMmeI na)
I svWe am the designated agent MIDI dewawd deaignetad 'm a will or wntlen 'mxWmeM executed punuam to Public
IINm Law,bectvi 4201.
-OR
SlMe Mlle no knowledge that the dewa5 executed a"ten instrument pursuant to Publb Health Lew Section 4201 of
will containing dimdimsW me dbpositicn M his or her remains and Ilse are the deal having di under Public Health Law
Section 4201 and have the fight W aomadae want of the remains Mme dewaeed Mynan mletlonship to Me defended M Ad
bllows:
Robert Eugene Walden
00S-109hr IRev. o@0) Page 1 M3
_ Authorization for Cremation and Disposition
(Inert Home Jig bebw)
Number: 3 parrou art Surviving Child
1. A person designated in wrNng pursuant to Pudic Health l.ew$e m4201(31;
2. The surnvirp Rah
U. The surral dameaec"mail
3. Any summra mild radial"am or age orwer',
a. AsuMvaq parent
a. Adrmmna sibling eighteen yeah of age or all
S. A thorny appolmed guamiaa
T. Any perform)daemon years of age or other deal M snare in estate and who blare been in relalmnblp to To decreased;
B. A duly appointed foundry of lM order,
9. A dose friend or relatve who has moraled a written statement punmet b Public Health Law Samon 0201T),
10. A chief barrel number Ol a county or a publlCadminidralmagaMed pursuant to Me Surrroper a OWn Ptondore Aql
lass Any enter porter who is ading on behalf of the deceased and who has meal a written statement pursuant to Public Heath
Lee sorrel Azmol.
(mmai ALL THREE draw rmrom m)
iawe hereby gran that the body of Me demanded does rim regain a battery, battery pea, power cell, moradlm implies
or radioecdve@viR and that any such mal le were removed poor b Me e[ewMn of this AU dxaaon From Falluu Wo o
t[QM`�or Mms pear b cremation Most malt In hart W Me cnmerory,and cremstory personnel.
Me affirm Mal instructions have been given to David Alexander
regarding me remooal of any personal pgreM or done,Ming of value whits any Parson signing below or any family member of W
deceased cashes to preserve. Pine View Crematory
hwnnrx.w
stnel responsible for Me hal l 0 perednal items from the container or for he remains of the tlewaard. PeMO"Idoms intM
co inerar MM Me remains will tow Metroy by the arose lon pracna and mnnm be reb Wafter cmmgbn.
S lNe hereby auddorin Pine Vii Crematory
r,T*+M r+ry M crmred Me remains W the dacaaeW.
)limier OPTIONAL)
from hereby, authorize Me named funeral alrector to provide for delivery m and common M an alternate
cnwddl N deemed secondary in Me opinion of the funeral dlrmoor,and to amend his form M provide Me coma name and
address of such alfemate mmaWry.
FINAL DISPOSITION
The pang, alumornsual to reoeive me channel remains otfue deceased from the oemamryie:
Neme'Alexander-Baker Funeral Home, David Alexander
Address'. 3ND Main Street Warrensburg, NV 128M Phone: (518) 623-2065
The uemated remains of measured will be disposed of as rogows'.
Return by family
If for any Mason Me person remW above does not had pn MM of the aemaled remain,
Pine View Crematory is authored to give pcesessidnof
Me remains Alexander-Baker Funeral Home "Irmry
In perwn or or registered men. Robert Eugene Walden
DOS-189840fev. OARb) rx�» Pa9e2dS
Authorimflon for Cremation and Disposition,.
f�l dre iumathg)
Ste- Me armament NN rcrM margins are not claimed WtNn 120 date oraamNun.
First View Crematory mgy eispoae mime remains In
na.wrn's"w'
an nnedeame manner, soon as by scsMennit
LREIM9ON COWAINEWURN
moved ME of the Menowny
Alexander-Baker Funeral
An um to be u9etl as a container for the command temaios has Offer,PUrche ad from
and is deacnbed as bicobm:
Ma understand that if has um ®too small to noW Me voted uwngW honest. an addi ional r9N container my,be used for satisfy
-OR-
S� Anamenbystimmommed. Invaun roOnd Netdmumisoumhamdordlw isepMked
Pineblew Crematory will place tM aemalee mmainsin
T"adii
a neid temporary consumer for de w faY
This Amb ab nForm was pri by David Alexander sasvnvomvdN
Alexander-Baker Funeral Home
3808 Main Street,Warrensburg, NY 128M
i
and is signed by the funeral dimmor as anMess to its oxymoron
Me have revived a completed wry of this AuMorizaNan Form.
The pdrsoMg IdamlNd Wow Items the presents)in Control of dnlwsiflbn,who by signing this Authoritarian Farm, a bsi
Its the acsuacy and CompMMnass of the information combined in this AUMorinean Form and authoriutq the foragaing.
8lgrud this 2nd tleY of July , 2e 2N / / jZ
Shanda L. Kearney ////,[
bwsawa,w,. ryaar�
24 Columbia Avnue, PO Box 9, Fort Edward, NY 12820
obai
WRNE88:
David Alexander
loamrwsggv. l Ns77
Robert Eugene Walden
00$-1Bg&I(Rev. 0d120) Page303