Wright, Mildred Anna Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 your (518) 745-4476
FUNERAL HOME: �UhP f RETURN TIME:
DATE S TIME REMAINS ARRIVED AT CREMATORY: 7II I IU II��D/II 1
NAME OF FUNERAL DIRECTOR OR REGRISTEREO RESIDENT DELIVERING REMAINS:
16T
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NAME: NldeRr M�L�I' CASE # -183
TYPE OF CONTAINER: TT �II'' ,1 �9k�e w
// _5 . Y H dd 3d80H.
PLACE OF OEATHI 'FR H 1'^'/SwA wow. 1I
ESTIMATED WEIGHT OF REMAINS 8 CONTAINER (3o ILe / IOO Wr
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION: y� 7)2Im,
TIME STARTED: _ IDArL-TIME COMPLETED: 11 �FCFIpp,��
PLACED IN RETORT: 74fAA_MOVED: g'�� :I• I
RETORT # IN WHICH REMAINS WERE CREMATED: Sl.t_ry k
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 98 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SHALL BE RETA:NeO IN THE PERMANENT FILE OF THE CREMATORY.
Nra Dexnmmm ma re
Authorization for Cremation and Disposition o ,n�
om�rA �®aw,.gevxxmywmma..nw
am
e (518) c83]fi
This AlModaabon Form mustlM compkaMaMsigned Prior m dWAl of Ramada forprematlon.
Date: 7ht7o Number: 7S3
Crematory Name: Pine View Crematory
Address: Quaker Road, Ouansbury, NV 12504 Phone: (513) ]45J1]]
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cramalion is cannot out by placing Me remains of Me deceasetl and the container holding the remains into a
cremation chamber where they are subjected to intense heat and flame. The heat and flame will Incinemle and
consume everything except bone and metal, which are all that will be left after resonance.
Fallowing cremation, Me crematory will take reasonable efforts to remove all of the remains and other material ham
the cremation chamber, but some minimal dust ant residue will likely be leg behind The crematory will separma
incidental and foreign marshal hoe the remains and the material and foreign material will be disposed of as
required by law. The cremated remains will be mechanically pulve¢ed into small Precis and placed into a
designated container or um. Cremated remain generally are PUNMzed unfit no single fragment hi
recognizable as akelatal Makes.
OPENIN"ECDNTAINER
The crematory may only open Me container holding Me uncrematad human remains in limited circumstenca, such
as to confine Me silently of the deceased or M eni that no matenal is enclosed which might injure employees or
damage crematory property. If human remains are delivered in a container which is not suitable for cremation
such as a ceremonial or rental cal the clwnstory will require Nat the remains be moved into a suitable
container Were it accepts the remains. The opening of a container or Me tra emer or removal of remains will be
conducted b m a witness and will De done in privacy, wild dignity and respect.
IDENTIFICATION OF DECEASED
Name p 1
Name of Deceased moll&e� 1-�vxvv Z c^ Mantal Statue: . tell
Last known Address. `]A4 ^ �f(1`� +d�` I t f•IN 11V,-�'
Place of Deatll: �} y�YK()/x 1V+r�y �^ lyuhe �n
Sex. ElM I$F Age: CID DOB:OAIMI IJA Date of Deal: &[A IWO Estimated Vkhri
Description of caskegcentalne in whidh remains will be delivered.
w.LA "ll Sit Y R441 M 3til
PERSON IN CONTROL OF DISPOSITION
(Pe2n(s)in mnbW a/NWosilion, i aIIINJEd Me klbwing)
NJ Iaml Vtle arethe designated agentofthedeceased designated Ina will created instrmmentexecuted
pureuam to Public Health Law section 4201.
-OR-
li have no knowledge Mat Me decaased executed a wnitwt instrument pursuant M Public Health Law
semon 4201 are will containing mrecnons for the disposmon of his or her remains and (Lmaneedrwxlpepel
rneu�,a
Urmi-I&OM nel12ihu w„m.wwoi we Fw.hd]
I amf we are the Cannabis) having Moriry under Public Health Law section 4201 and love Me right M aulhor¢e
cemwmn of the remaiinofthe deceased. My/Our relationship to the deceased is as follows:
(Insert from Me li96ebw)
Number Description
1. A person designated in wrifirg radiant to Public Heats Law section 4201(3)I
2. The surviving spouse:
U. The surviving domestic partner',
n1 4ny surviving child ephteen years of age or older,
A sumving pareM:
S A surviving sibling eighteen years of aye or old":
S. A lawfully appointed guaraanl
T. Any persons) eighteen years of age or older entitled to share in the estate and who Was closes) in
relationship to Me deceased:
S. A duty appointed fiduciary of the estate',
S. A close Mend or relative who has exerted a written statement Pursuant to Public Health Law§42G1(7):
% A chief fiscal Caner of a county or a public administrator appointed pursuant to Me Surrogates Court
Procedure AM:
t0a. Any other person who is acting on behalf of the deceased and who has executed a when statement
pursuant to Public Health Law §4201(T).
pnfi&AU THREE of the fdlowlrg)
t-luL Mwy hereby affirm Mat the body of Me deceased does not domain a battery, battery pack, power cell,
radicar dive implant, or radiwcTve device and that any such materials were removed Four to the execution of this
ANhorcia din Form Failure to remove these Nems pdorM cremalon may result in harm M Me cmmarory and
channel personnel.
t '_ ]Me hereby affirm Mat instructions have been given to tr,,ow wmamiwo Stan Baker Li0#00154
regarding Me removal of any personal property or other Ming of value which any person signing belmv or arty family
memberotMe deceased wishesM Preserve. (mmuch,aw) Pine Yew Crematory is
not
responsible for removal of personal items horn the container or ham the remains of the deceased. Personal hems
left in the container or was Me remains will be destroyed by the cremation process and Cannot be retrieved
after cremation.
W IIWe hereby authorize (owon hovi Pine V� Crematory to cremate the
remains of Me decessed.
FINAL DISPDSITNIN
The person authom ed to mceive the cremated remains of the deceased from Me crematory Is
Name: MaynadO Baker Funand Home
Atldresc' 11 Lafayede Strea .OueenWury NV 12304 Phan: (518) 7814phO
The cmmaed remain m deceased will be dKpoaeE of as follwvs:
Return to family
If for any reason Me pennon named above does na take preseason Mate consul remains,
pwwkry�.mt Pineyiew Crematory cautha¢ed to give possession of the remains to
rwo,o, ,,Can Maynatl D. Baker Funeral Home by delivery in person or by m
` pygninered mail.
nl1KA(1 ( k°GA.T
O0a.111 il� rm Otlral mar eyeser]
rbrflal dre/atlonnpl
r U, LVde understand that gibe remains are not claimed within IM clays of cremation,
Ir,w,.uy,j Pineviewcrematory, may Matinee of Me remains in an imedievable manner,
sued as by ecaaenrg.
CREA1AT1O�C NTAMEMRN
(IUdlal ONE a/me(dlDwlny
An um to be used as a container for the cremated remains has been purchased from
Maynard D. Baker Funeral Home and is described as follows.
Inds understand Mat if the um is too small to Mid the snare choosiest remains, an adclNorel Wid container may be
used for delivery.
-OR-
Q.W An um has nor yet been purtlms id l A undeMand Mat if no um is pure or otherwise provided
rmmtMynamer Pine view crematory will place Me cremated remains in a rigid temporary
matainer for delivery.
This AMhorizaaon Form was provided by Stan Bakerl-FDOEM15a _
wasexecutedatrMe,Ybmnemw MeynaND. Baker Funeralltome
Ixn,.,wnnmaaxsW 1l lahyede Sireel. Dueenabwy, NY 128g4 add is signed by the finarel director
as worries to its execution.
Nye have received a completed copy of this Authorization Farm.
The parabola) identified below Were the person(s) in control of disposition, who by signing this
Author elation Form, abentia)M the accuracy and completeness of the information contained In this
Authorization Form and authbdmis)Me foregoing.
Signed this 30 day of
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Funeral Nome Beg. #01130
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