Schenk, JUlia Pine View Cemetery & Crematorium
Quaker Road
Queensburyl NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: M1A rTI MFQ RETURN TIME:
DATE B TIME REMAINS ARRIVED ATCREMATORY; 7/1 / 10 r90Qj]
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS: -
5TbNAKe 911MAP
NAME: SU11A germ" CASE S lir
TYPE OF CONTAINER: LI N We W �/I D
PLACE OF DEATH: Q ,YHIEB A* I IMSFU FNLJ IRA IZ ESTIMATED WEIGHT OF REMAINS E CONTAINER IZf ge
PLACED IN HOLD: D
PLACED IN REFRIGERATION:
DATE OF CREMATION: 9I Z ) U
TIME STARTED TIME COMPLETED: n.'xerl ry.�
PLACED IN RETORT: jf:w All MOVED:
RETORT O IN WHICH REMAINS WERE CREMATED: AoNt fWaig. d1
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 40 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE:THE CREMATION WO SHALL RE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
o,wmentolw"
NEWYORK Division of DMSION CFC UERIES
SiATEOF CFe Camn.zo Pleze
°" ^ Cemeteries AwaryNffI ^Are^re
lE,Owi
Teapbrc.ls,elaaeyixe
wxxJmmpw
Authorization for Cremation and Disposition
This AuMwlaaaon Form mwi as comp Wd and signed Priorro memoy,of remains/icrcrwnkuon.
Pote July 1, 202D Nodded �Rl
Cremaloy NWe: NmV Cmmalmy
.. 21 Quaker Rued Ouurebury, NY 12804 Phone. 518-745hAOT
CREk1ATION 18 AN IRREVERSIBLE AND FINAL PROCESS.
Cremation is corned out by pgtlry Me remain M the de:.eesM and the wnb r Whine Da Imnaim into a oema MMEer where
tray era wGeNdbin,Hn69 M1Bat erL tiame. The head and flame will IedlAmm and consume ov ing eFapl bona and mortal,
which am all Mile will W MN after cnmahon.
Following cremation. Me vemamy well teke drounu able aXortato rem now all of the remains and other material fiom the aema0an
chamber.but some normal dust my!haddra MII IlMely W oft behind. The dwmalory will wasymme modental and foreign mffieel own
Me remaim antl Pa inatlenal antl kregn memriel WII Cedlspmetl of as reouhetl by Iaw. The vemmN remain will be mecum ally
pulver'¢Be iMoamell olePm eM plePad Inro a deaignebd cmbinerorum. Cmmaled mmalns Wnsmlly am puNe l W uMI no
single fmpnrarM1 is mcognbable as sk llwue.
OPENING OF ME CONTAINER
no uemabry may only open the cumamer noairy Me ungme human lamains;in llmihtl arwmaundes such as to confirm the
aerldly of bar dawaeed or to ensure Mn no merited IS end whiN might care mocoyaas or manage Me uematory comedy. If
In uman remains am dMvemd In a container whim Is na suitable am cmmaWn such as ceremonial or all deal Me
wmnir will mgulre BMt Ma remains my moved late a suitable container Were Haccepta Me remains. Thooperhngota
Maineror MabaMler or minuet otremainsvAn Fe wnducbtl bebre a whnesa eM snit W eom in vnvacv. witM1 aigniryene resgct.
IDEXTIFICAMN°F OECE SPO
Name of Nw sW Julu Schenk Name I SUN$: taa't'm
Lear Name,wid ew, 6Jones A k, HWson FWM, NY 128M
Piece of Il Jum Pre., HWaon FY". NYlMN
For DN ® F AM, 80 Skye: 4/19/1940 Data a Deem:E13(cl estimated weight:
cescrips"of oskNwntaner in wMlol remains ell W MIkkyr
Minimum Cremation Casket, Florence Casket Co. Cardboard/Pine
PERSON IN CONTROL OF DSPOS1nON
(Pepmou In cmlml Ndrswal er ONE army M4m")
I anCM are the designated agent of Me eeteased mswn In a sill or wlXen Instrument executed pureuent to Public
marts law Surfed a201.
OR
�WJe have M knowbtlge MeriW mwesed exacNedam imN t pursuant to Fund Human Lax Segion 4201 or
will containing 0irei for Me dagaition ofhis or her remains and Wig am the pemon(s)having moriN under Public HUM Law
Sedion@Ot and M1eve MergMbeumor¢e aanaWnof MBRmBN9of Me MxMM. WMurmiadonenlpro Madwusedlsae
Wayne
Julia Schenk
Para
o01 189434(Rev_U20) Page 1 of 3
Authorization for Cremation and Disposition
NumMNumb fianlMNaf Oebv1
r ' B..rrman: The aumlMre.Pets.
1. A IRROn Magnsium wiling pureuanl to Pudic Heats Law S on U01(3)
2. Me surviving spouW;
2a. Me survlvm6 domestic partner.
n Any swlNne chile Hghg roan of ag3 of older
a. Asummer; wmnc
5. A suhmi Sibling egM nyears of See or open
S. A year 6 o'ueed gwNian;
T. My pRon(s1 agMSSn yae9 M ago 0f came en4lbtl W$We In Ma aMM and who iyere coal relaticvMp toile amend.
a. Aduty eppll fidusery of Me eNM;
9. A coma Mail of mlative who has exrread awriN menl pursuant M Public HmM Law Season4201Q},
10. A cash fisalofficer of wunlym a I commissioner appeal Wrsuant to the Summers,a Cwtl Procedure Act.
10s. Any other gmeon who is acting a behalf of the dammed and"ahas executed a when statement pweuant to Public Health
Law Sedan 42 1
(/qmay d�AA,,LLLTy arm,a l
LJai- i Mreby eMm and Me body of Me dacea6w does mot after,a tal bathe.l prock power fall, mdloectNe Implant,
mmdloxB.e devmand Metal such metnatware remcrast MorbMaex onofMis AurM1wLatlen Ferm. Faeuremnmow
blameylb morto emmfim may resubt In Mtn arms cm =M cm and mal pmMnel.
l .(ms jj li afimi but InNugieM nave ceen given to Texas C.Kilmer
legal Bs,removal of any V¢sunal property or small Ming ofvalw whi any mean Sgnire What many famay moms of Me
dmapd Wafie9 To peeerve. Pine VIMCmme
'a not namvlbo M Me mmovel of pomanel Items hoes the moral or horn the remains of the Maxwell Pamp411bms Its In tlw
remember or Mm Me remains Mll M destroyed by the c er ation moves and cannot M nblrved after cmmmon.
�Y/Na thereby aumodae Pine Uaw Qemebry
¢weer to cm mine Mail of ds,den .
IbMal OPTIONAL)
IMv barely aumoMe me named esters Meadow provide for Museum to and rremaaon M an allmat
admalory.If dammed Funeral In Me opinion of Me fium it director, and to amend role farm b provlde me town name and
al dress of such aMmam rnmeby.
FINAL OISPOSITION
The femonv onmd to mmi Me unmated mmmem of the damosd For Ma nwmtory'a
Name: MB. Kilmer Funeral Home
AddMr 82 Besides For Edward. NY r1l Phom 5167474200
The aemat] remains 0f demanded will M Mitchell of as ldlwn'.
fur l0.r
If for any mason The Person named about doer was toe pome9Lw mtlm veinaW amend,
Pine Uew Cmmlory in auC2i¢ed bgive Msseasion of
seasonal
me remaineto M B. Kilmer Funeral Hormy by delivery,
MMmw,
in person or y happened mail. 3pt Sds,nh
0O5l89 f(Rev. mi mm^ Pi 2 a 3
Authorization for Cremation and Disposition
(aggits me fneoWg)
At IMR apeman that remains are not calmed wlrbn 120 days W changes.
Pins Van Cmm=o may dispose of the nmaire in
an rode ble manner.such as M aoabdg. ,n'w N
CREWTON CONTAINERNRN
(bastafONEdfne N'bwmy)
An um To W used as a springer Vthe oremekd relwns Ilan been purchased harm
and is desulied as bllon'.
INJn unen M that if Na um he ad mail W held uw mares OamN] remain.an aMieonal rlala anbim nary W used for dandy.
-OR-
Anumbasyerpurchased. VAN uM MWW Nat If its um b peNexd aotlwwix provided
%M vm Cmxlory art Mean Me eamatel remains In
ffimiscmi
a Mid rampwary mnramerWMeMVNy.
This AuMaAaatlm Form wee provided by TWd G' plower was exwoe at
MIf Hilmar Funeral Hosts nvereoxvmv
n mow 82 Mountainsdwry. FM Eduai NY 12828
lsaoa�.
ends Mount by the funeral director as wlrnew to As mindmi
INJe hew appeared WmpWW stay of this AUMohended Form.
Tnep n(a)I Med Calm Wan Napnaon(e)InconOOl ddispoelrom who by signing this AUMONaance Form.aMeNa)
W tlYaeeuneyand emmplln NMs lr MS&n conM1lmd In Mb AuMdtleat Farm and euNodad(s)Ne forsgoing.
slenea Nls hat arvaJuM .gg 2a�+✓ ` C1
cNMd sdrenk �/J n'
8 Jones Aw.. HuMwr FaM, NY 128M
hasernerimare Arm,
Arms
WITNESS:
Tape G. Winner (I Rid
uvmis�rvmmwmN m+wr.
lien
Jon Ynmk
DOS18g f(Rev. ist pgNds