Riley Sr.Jeffrey Pine View Cemetery & Crematorium
Quaker Road
Queensburyl NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: d6 Kgtq . RETURN TIME:
DATE S TIME REMAINS ARRIVED AT CREMATORY: -IITIIU I. Y6fry
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS: -
NAME: Qw!q R%aj 1CIASE0 70
4 TYPE OF CONTAINER: GI M WIGVLG A*a:SEd
PLACE OF DEATH: all Ktu RPV+C
ESTIMATED WEIGHT OF REMAINS 8 CONTAINER I Irlc IlT
PLACED IN HOLD: Z.p Pq
PLACED IN REFRIGERATION:
DATE OF CREMATION: 7 S-ZOZO
0
TIME STARTED � TIME COMPLETED: I{IJ —
PLACED IN RETORT: A MOVED /` ^ 1'�/ �
RETORT # IN WHICH REMAINS WERE CREMATED: AN rp. k1L
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 46 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG $HALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
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NEW PORK Division of DWMN OF CFMETERIM
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Authorization for Cremation and Disposition
This AuN con n Form must be cemplMC and sgnetl prim to deVmry M nmalrpu Nor nenoticn.
Data July 2,W20 Number. 79�
Cnmerory Name Xrc Yi9e CnmdI W y
Mdnu:21 Quake,ROM,Oueenkral NY 128M Pbwe, 518-745-041`1
CREMATION IS AN IRREYER&BLE AND I'lli PROCESS.
Cremation is armed out by placing Me remain OF Me de Wend the mntmar bd]irg the remain Into a annual chamber where
they are subletled tointnse heat and Firm no hail and Nm ,will lncimr amid censume everything eecept bone and m sj
which an all that will be IM after cnmadon.
chamber,
coo smarm Ne dust and llakere Oil
eflMaorremove no co1Na remelrcantl WhermeNdellam Mena real
M emM, but sdne Formaland foreign
wooluinimu likely he drwmwleft md. as Motimnby law.11 The ca incdenbl and hall W melenel M1om
Ma nmainetoa and MeI Pecurylaend Ioadi into
alenalwilled cumber Krputredbylaw. TM MemMil Rmetrc" ba unginO
sueddIntosmall pewsendplatedintoa tisignaletl ¢minor Minn.0 Cremated remains ynMllyMpulwdvd unBl ne
Nrrylahagmenl le rew8n4able as ekalMl tissue.
DPEXNG OF THE CONTAINER
no GemMory may only open the container holding the YnSRmekd human remaise in limited circumstances,soM as to wnfiml the
muhrof Ma dewaeM W t0 ensure that no matdal is enciceatl wh'rch might injure empbyew w damage the cematry propeM. N
human mmMha M delivered Ina container which is hot nitable tar moral such as ceremonial or nodal caked,tin
crematory,MIF require that the mm ins be moved Into a suitable wntMner bNDre N accept the remains. The rmarrang Na
mmamrt or the transferor remowl Of remains will be conducted before a wMess and will M done in pnary.AM dgntry and reaped.
OENTIFICATION OF DECEASED
Name of OeceMM1JBftrBy Riley Sr. Mai lstatus Marled
Last Known AddreN:ma St Rt 197 Apt.2, Aug re. NY 128439
Piece W Death Glen Fells HosptW, lag Pe*Sears ,Gkn FeN, NY 12MI
se.: OM OF Agee 59 DOB: 12/20/1W Dot M Down.711 e0 Estimated We Rm: 185
Dissolution M caekMlmnlainer M whim remains AN M de rembou
Minimum Cremabon Casket, Florence Casket Co. Dardboard/pine
FERBOX IN CONTROL OF ORPOBRION
(Finaw(M in cored Ndavrnvdien,larded ONE OF rlrebb )
I YnMh are Its desgnM "and of Me demawd daegratd M a Are or wdtlen instrument executed pursuant to Pubic
Health Law 8ec0on 4201,
T-0I �Rn--
is — Me have no knowledge Nat the demased executed a Oman instrument pursuant 10 Public Health Law eectan 4201 or
II mnbintng dlnetiens M Me lisp amon of hie or her remains and Me M the parscn(s)bai monry under Pudt HwIM Lew
Spoon 0201 and Maine the near to mimedm demedon of ma remains of Me dewerem WOur mIWomMp to Me dwea3W is Ad
Mlwa:
Jeffrey Riley Sr.
w,.aw.a
303-18984 gh y.(i Page 1 0 3
Authorization for Cremation and Disposition
(Insert/cam the And Dabw)
Numi2 D PipOon: The aural shaped
1. A Wool designated in wring pursuant W Public Heats Lax SecKel 4201(9):
2 TM aurrwing Miami.
Ms. the survMng cmreetic parMer,
a Any surviving child eighteen years of age Or Older,
a. AeuMving parent:
S. A moral sibling notawn years Malta a ones
6. A latMd%appointed guardian
7. Anyp mo(s)egMen Whom of age or miler entitled W"in in me eabte and Who Hare cbseat in relationship mina damced',
S. A duty appointed fiduciary Of the cards..
9, A Hose Gam or homes who has executed a wntlen Mitement pursuant W Public Hill Lew 9acmn 6201(7):
10. A chief fiscal mendr M a Perry or a public ad maniacal appointed pleasant to lie Smople'a Court Procedure All
103. Any ONar probe wm is acting on behalf M Me damased and Who has executed a smash ataremenl pursuant b Public HWM
Law SeGim 6201(7).
Ming 77"1 of the member
ze Me hereby affirm that the body of Me moraldoes rot wntainaWendy. batMry crack power call. radiueNwImplant.
or redmirc0ve here and that any such materials were remoeed prior b Me execution of this Ao dmtk Fruit. Falluetoremove
Mesa Items gporb chiral may MUX In berm W Me MMm aM emntory parsonnll.
DK Me aRum tfaa inufacturs have been given W TMO G. KIMnr
uwxuvxeml
regarding the removal of any sma l propeM w other Mln001 vales wnitlh ant pereorh spin becw Or airy funny member of firs
tlettased same to preserve. Pine View Crematory
ie mtreaporsAle br Me removal olperwnal 'hleme cam Me PMeirnr whmm ate remeln Mtm decemed. Perwnal IW ins NR Intln
manWlrraf orwlM Me remains will be destroyed by Me command process and Cannot IN,M fib aNrmmtlion.
DQ. MenerebyauMomm Pihe View Crematory
Nwucv W orerrrNe the ramalm M the de Ole .
(InAZI OPTIONAL)
Are hereby authorize the named funeral director to provide Nor delivary W and cremation by an amrnab
remNory.Ndaemon necessary In the Opinion of the funeral Metal and to amend Mebmr to prawMetin own name and
address W such alternate Monetary.
FINAL DISPOSITION
no person auMONbd N real the command retrains M Me Measure from Me monamyI6:
Name. M S. Kilmer Funeral Home
Mdreu: 123 Main Btrsel, Al NY 12101) Phone: 518E28d216
The cremated remains of daemon WY be depYM of as blMe:
N fin any reason the Matson mints Many,dent mf tents pYNeYM orthe unmated carriers
Mine V Crematory IS aunt W gw Mseess of
aw annM
the remains b M.B. Kilmer FUPreI Home try defier
m In person orby equal mat. dePoey Flky&..
DOS-1998-f(Ages.capped Max Pages 2 W]
Authorization for Cremation and Disposition
(i1/1 the tdlpadpgl
�W y . buys uMdstand Mat If the remains are na claimed within uo days of=re on,
Pine Yeu'crematory
may Jammer ama remelmm
an imalava0le manner. such as by seananiq.
CREYATM CGNTMNEMRN
(BONE oft ay;fam ng)
M um In W used ad a PoTainer for the IXENba 2maNa has arms purchased!More
and is moemhed as WY s:
Me unaermal that NMe um is too small h Wit Me enure vemnM amalm,an addlimed rigid mmcnm may he used for delivery,
-OR-
M um la him yM purcnaeed MNeum nd MMgmumispumhasWorotMr span'idea
she Yew chemistry Wil bear Me command remains In
vu.ao�r
a n9itl temporary consider far dinner.
This AUMalution Form"a pravitlM by Todd G.holster was summer!at
M.B. Kilmer anneral Nome Fumurvx�N
123 1 real Mgyla, NY 12009 M~��
and Is signed by Me broad diredar Me utlneo to iI s execution.saa.H
Me have remrvad a carpeted may of Nis AUMwuatan From
The persorst MCMlhed baby Were Me persona)to small 0 ifespeslllnn,whe by sign Ing Mi ,Ammunitions Fisher,attesgs)
ie the accuracy and complaNnau of the Information confirmed N this ArM orleeYon Form and inseminate)Me ofegeing.
signed MM 2W day of July O20
Gelmren Rim 1
" 4LN 5ia, pAe hl w 9 Ae 41
dy h�
sui
Aware
g Todd G K
Wtl .Kinser
11g]9
JMraym S.
disease
DOS-1g f(Nw.Orehl) Paill