Bennett, Richard Pine View Cemetery & Crematorium
Quaker Road
Queensburyl NY 12804
(518) 745.4477 or (518) 745.4476
FUNERAL HOME: E O $ RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: 1/1 I70 I1' 0
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS: -
(auLGN W✓8TE7R.K1
NAME: %Tzwyel) nihiorr CASE C -7Q
TYPE OF CONTAINER: MSH�A.E - (� µLy u. :M
PLACE OF DEATH: IJ_ Ry.r ✓F..M I 1 'M.. i:YS IJI. IRi9
ESTIMATED WEIGHT OF REMAINS & CONTAINER �i0 IM
PLACED IN HOLD:
PLACED IN REFRIGERATION: II�4r(
DATE OF CREMATION: 9I2 /70
TIME STARTED: JVvMI TIME COMPLETED: (U AI(Ip
PLACED IN RETORT: -160 P4 MOVED: (/ 46�
RETORT N IN WHICH REMAINS WERE CREMATED: &Lftt Le-Ty
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SHALL BE RETAINED IN THE PErtmnxem FILE OF THE CREMATORY.
�1 ONer now York
Yb
EWYORK Division Of orvlslox aFwNaraRles
SriIEW cegw
nWO0.TM11Y. Cemeteries NNnynHYmII]TW01
TimonsW 1518I4716226
Authorization for Cremation and Disposition
TnISAUMafiaxon Form most b core~ eM Sign"War W dWNery a nmelmbr cnmetlan.
[tray. 06/ 912020 Num6x
cmm"Name:Pim Yaw Cmmatonum
Mdrera:51 Quaker Road, Quarranstil NY 126OI Paoow: (518) 7454471
CREM WN IS AN IRRE RMBLE AND FINAL mOCE96.
Cmna4on is Word cut by plating tM remains of the tlenax]and IM container MEing IM remains Imo a uerrall chamber wfien
they we subjected W intense neeland flame. The na danaflamewlll MCMs"and consume avaryMllrg eawpt acne and metal,
watch am all MM will be IM alter common.
Folmar lg nernal me uemMo will Wks reasonable all to remove all of the nmei06 art other maternal from tar cremaon
clamber, but come minimal dust and residue will likely be left behind The abandon"will sepaMe inademal and Small material had
the remains and the Inclidemel and larman material will be disposed Mes reguiretl Cry law. lee uemelW Rmtins wiY be mecNnidry
Wlvenzed irdo small blears art plMed into a designs mlXaiMl mum. Cremebd nmalm gemnlly an WlvwtrM uMl no
smelehaemem i. rwvgnlvbxr.kelMal tlsau6.
OPENING OF THE COHTNNER
The crematory may only down Me contrarian hoping the on-cremated human Ismael in limited c,=m n¢ ,such as to confirm the
inertly other deceasedonto ensure Nat no internal is endowed winch might injure employees or damage Me cremal prepery, x
human remains are del verad Ina mnnlnel which x nor suitable for monsoon Such as crrenommal or MM l cal are
nmMq will rapids tMt Ne remains ba maned Into a suitable consu ar bMon xaacepls Ne n im. Chancel
wnrzlner or Ne Inhaler or remwel d remalnsx+ll be mrMutled bNare a wiNmS art will M done in privacy, with dpnily and leaped.
DENICFICATION OF OECMM
Name of lxdeare RichertB rrrren NeMN s1Mu Meared
Iaet Known Address:12 Devine Dr., Hudson Fells, NY 12839
plead M Dned, 12 Devine Dr., Hudson Falls, NY 12839
yes: 19M 13F Aga: 68 0139 ON1311951 pay Of Death: Cfet?W2020 Esy dddwNi 160
Deedngicn a mskepor ,ear In wNM remains will be arrested.
Alternative container without interior. Matthew'a Casket Co.
OF O
Commonly)M wnfm&ayrosnron whom ONE ar ma model
I anuWe are the designated All M Ye QtBased deMg M a rat a what Instrument sassed pursuant to Public
n 4201
OR-
IhVen no
knowledge that dafined ezandand a women mMNmentpurand m Public Hearth Law 5M4on 4201 or
wmamrlg dire for the Snowdon M his wheat remMns and M war Ne gwsl sail artery untlx Public Health Law
Section 4201 eMetghlmauthonmuemerondMe in¢WthedewsW. WY rMAomalpWMedemm iSs
Mlu
RiMard Berman
Dp5-19%f(Rev. 04,20) Page 1 of 3
Authorization for Cremation and Disposition
tmmdgpm Malrsrbemw)
Number: 2 pesmption: WXe. Pal J615
1. A peremi designated!in"" pumuemlo Pi Hewn Lear Swoh 4301(2).
a me scrvmmg spouse:
L. Ibe wrvlvmg aomewc pa"r.
a. Aiy wrvning wild eynteen seen asps of alter.
e. Asummer Mrent,
& A surowng sperm eighteen years of age m Order
8. A 4wNlly appointed gasman,
L Any parson(s)eghteen yeah or age or older snared to sham in Me aws and add Hare closest in relationship to may decades,
8. A duly mounted liducary M Me essall
9. A comes Mend or relapw Mw has command a wnttenstatem¢m premium to Public Health Lays Swoon 0201(1):
1e chNl flgcal OlM1coroIawunty or a public adminlsmdMr mounted pursuant to Me Suocgatea Coal postal N];
abler persm who ie among m behalf Of the temasM and who has e1wwd a wMten a Wmem pursuant to Public Heatlh
IA� �aEECJ
a201p1.
(aag' rMMe Mbwwp)
reby afrm that the bdy of Me EBme9ed wsM m na hatlery, p ery pack, payer fe , radioeNveImp4nl and Mat any such malenals were removed proof to Me summit of Me AUM atlon Form. Failure W Mail
Chapard,
Nmora lan may result In harm W the amatory and chanelary "r ml.
eeMrmMtlinWudm9hav¢ b¢engivento
�d dVanShetline ov.l say,pemonal plgMy o,aMr thing ava4whkh any pamm taming ancestral family member of"
awes wlwm W pnesrve. Pine View Cremetanum
m ek ror Ce remavalapenomin.ma M1om Me waaim,w Fold "Miami
aMadweawd. PemwNl lNme "InW
coLntal Ma rarulm at bs Mys bytM claims proven sand chnnot he mrMrad afteranmaaon.
�u • harmagee nor Pine View Crematorusamanym
r m cremaro de mmsim;a Me lma W
CNAU
IMv hereby subscribe the named funeral director to prorms for dollvary to and cnmadm by an tlamam
Matthews. H deverad necessary in the opine a Me hmaal diussa ,and W amand this form N prevlM Me coact name and
addm of such albums cromaory.
RUL el8P0 SITI N
The paao ahmrsed W active be tlaMNt nmame of the rental from Me crematory is
Namur Patricia WENS
Adtrem: 12 Devine Dr, Hudson Falls, NV 12WI)l Pnane: (518) 793 16
lMcsareWlwrelm tlwAlMdspnNdesMmxa:
Hetum b PaPatriciaL.1CA%SG15
If for my maws they pmmwmt Maw dm rid NN pcwMm of the aemaW mmaim.
Pine View Crematorium maNh Wglrememmama
mm..rw.w
de femme W Regan Denny SteMard Funeral Home by vary
in bar w ly"armed mail. larwam a Ritllard Bennett
COfr1B%l(Rev Mot PyF2d5
Authorization for Cremation and Disposition
fkh�dw rox my
pYy uMm 1M HMe mmelns are no seemed mien 120 dap o/manytion.
Pine View Crematorium may disrpe Of Me nmeim in
and manner, such as by scab nu+.✓ram
D
faapl aveorme mwwmat
An um to be use !ea a mmainer for the vadadd mmYnn nos been purchased from Regan Denry,Stafford Funeral
end ',a aeesiced w rouowa:
41Ve once Hal Mtlp um helm vrWlMHdtllM eMm nranalM rerruina,an eddHionel nytl wmeircrmrybuaMketlNYery.
um YrMyelPnlhaaed. OWe ulgeheWtl MtlHm umY WrtlraetldrotlpwW ggYtletl ',
Pirre Ylaw Crematorium hdl pore Me<remaled remamem
rra.wo..�d
•r91d M1m W rary wnircr M dMMry.
The AMwtr Foods was provkM by Caaeidy Von$tetUna was executed at
Regan Denny Stafford Funerel Home
w..ex e' 5g 53 Quaker Roed, Ouaaabury, NY 124
ace a shame he Me based der 4r an wasess as As axsWGmh
IWe Mw ramrtxd a mmpNa]ashy of Mie AUMosaaeou Form.
lM pnoMs)fds ed blow Were IM weans)In control W domemon,weed W shares Me Auawrbaeon Form,aWsgs)
Is Me accunry and compNYmx of Me Mbrmadon candidate in MY I ulM1erhNon Form aM guMortre(d the bn eve r s.
Slpnad Nea 29m day of June
Patricia i
12 Devine Or., Hudson Falls, NY 12839-
lyffaE88:
Cassdcy VonStedina
m..aaawr.m.ewmwemw o�' + �'
13]09
Richard Banema
prrw�
D05-169&1(Rev. 0420) Past sea