Laabs, Rhonda Lynette Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (510) 745-4478
FUNERAL HOME: RETURN TIME:
DATE 6 TIME REMAINS ARRIVED AT CREMATORY: III 1 LJ I0:4941
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
rH D NAsleb
NAME: ELEAc 6E6 CASES -197
TYPE OF CONTAINER: `aNR4 ai(Mtp pµ- rly./1( N LiI [ Bfccg
PUCE OF DEATH: 181 em CiGfFX Qf� /' I GA fsllf l-`) niol
ESTIMATED WEIGHT OF REMAINS S CONTAINER ILO (M
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION: 911 )'Po
TIME STARTED: 1I1IMPl? TIME COMPLETED: zAO t)
PLACED IN RETORT: IU)O PH MOVED: I: Y0fril
RETORT # IN WHICH REMAINS WERE CREMATED: 40 st PoWG
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN OS HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE:THE CREMATION LOG SHALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
NYS
Authorization for Cremation and Disposition m01stew
On,Cwhara not,w.rvelan Awrw
NNM-aY 1am
(a1a)x#@Pa
x...w.eo..m.w
TMa ArdWdafba Fenn adopt W cOnW~sadslga price As deevsry of rem farnernatlon.
Date: -?/1Iy Number. -797
CRmgory Name: Pine Vk Chancery
AOOrew: Quaker ROW, 0ueensbury. New Yors 12804 Phone: 15181746-44T/
CREMATION IS AN IRREVERSIBLE AND FINNL PROCESS.
Cremation is carried out by pleoirq She remains of Me dit"s and Me container holding Me remains into a
remglon chamberwhere they are subjected to intense heat and flame.The Met also game still Incinsrab and
consume ever/Ming except hone and metal, which are an Mat wall be laid q rcrematlon.
Following cremation, the uemarory will take reasonable effort to remove an of the small and other material"in
the cremation chamber, but some minimal dust and anno a will hear be all behind. The crematory will separate
ncidental and foreign material from the remains and Me Incidental and foreign mgenal will be disposed of as
regulrW by law. The cremated remains will be Mechanically pulverized into smell pieces and placed into a
designated container or um. OrematW remans ganerally are pulvedzM until no single fragment as morgim able
As skele0i Sasue.
OPENING OF CONTAINER
The crematory may only open the consumer holding the unoome human remains in timbed circumstances, such
as to confirm the iden[iy of the deceased or to ensure Mat no material is enclosed which might Injure employee or
damage cemetery property. Ifhuman remalre am delivered in a container which le not&unable for cremato ln
such as a communal or mood caakK Me crematory will wall Nat Me remains be moved into a auilsblo
container before It accepts Me remalm. The opening of a container or the transfer or removal of remains will be
conducted before a worries and will be done in privacy, with dignity and respect.
IMNTFICAnON OF DECEASED `
Name ofDeceasW: MrondT I VV1LTt Lar10S MCMBI stews:,ys',Vpfte__d_
teat l(nosm Atltlre�eaa: (,fin �pY S 1 (�� � Cda., 'Enliki uV p^Paol
Place q DeaM: 1B`�w��1"A U. N �a14S i `a0
Sex-. CM IXF Age: 51 DOB:0)bj f46A oatsq Ddh:-"bpl,, EWneledV ft I00163
Description of caakeVwM finer in wheh remains will be delivered:
Corrugated CoWbo Box with PlywpW Starmork MWq S 30000
PERSON IN CONTROL OF DISPOSITION
fPe ws mwr Of dsposiion, Nalq ONE of the MbwiV
of Visa,are the des9nged agent of the dewa9W designated in a win or wrMen Moh me d executed
assured to Public Nealer taw section 4201.
-OR-
411 _ tM4 have no knowledge that the decades s executed a written
Instruent ee pursuant to Public NM Law
tlin 4201 era will containing directions for the diepwMon Of his or her remains and (Conlin W rrextpspe)
L22b�
opsleae.N new inn) rw,. mpo.ae vye t as
I aft we are thin demands) having thrombi under Pudic Health tax section 4201 and nave Me ngntM aumorae
cremation of Me remains m Me discussed. Ali reallonship M Metlpesse ! le as follows:
(Well M1Om the list hati
Number__q_Deecnm n'. M�Mu�I
A demon designated in among pursuant to Public Had end Lae respond 4201 (3);
2 The survMlg spouse;
2a.The surdvag command: pallet',
3. Any survirfdg child eighteen years of age or oral
G)A surviving pamm'.
5. A starving sibling eighteen years of age or duet;
d. A lawfully appointed guardian',
T. Any pemams) eighteen years of age or older entitled o share In Me addle and who opera cicada in
relationship ro Me discussed
S.A duly appaimed fiduciary of Me estate
9.A close Mend or relative who has a modeu a written statement pursued Is Public HeaIM law§0201(7);
10. A chief fiscal officer of a county or a public administrator appointed pursuant to the SuooMeWs Court
Pmced Ac(
10n. Any other person who is acting on behalf of the uCaini add who has execute] a written amend d
Pursuant o Public Hpli Law§4201(7).
doill MNEE of Me hisc fret
lA hereby al ism Mat U body of Me M seeddoesnd wnrain a battery, ba "a Po spas .
raliwctive implant, or radioactive device all Mat any such materials were removed per to Me execution 0Mis
Authorization Form. Fal lure to remove Mesa Rem put to cremauon may mutt In harm to Me cremHory and
mnarory personnel.
WJe hereby stand that instructions have been gilen toNeMaw..m.l smeBaker d10159 regarMea
the Uwe of any personal properly or solder Ming dvdue which any peen signing below or any lamAy mmnberd tice
tlece25etl wishes to preserve. ttnmxennemrl P'ne Yew Crerndary is rat responsible for
removal of personal items from the container or horn the remairn of the deceased Personal Ibms NR In the container or
"In the mmalna will be dotmy ll ed by Me commands pronams a cannot he Mowed after cmnauon.
x.(/ t^ ,I lease hereby suMOM lumam.y mmul C locremam Me
t(mr of Me deceased.
FINAL 010^O ITON
The person Bounded to receive the cremated mmains of Me deceased from the cmmalory Is'.
Name Baker Funi di Personnel
Address: 11 L Phom: 510 Z§l:1i 9
The cremated remans of discussed will be disposed of as fdloaa.
Return to family to be decided
If for any reaps the demon named abuse does net take possession of the cremated remain,
6wnrW^most PmV"ee CrsmaMrv
s adornment to give possession of Me remans0
MrvnlMnnml Bake by uaivery In parson or By registered mail.
„mil "<s
msram,.m,. em a,wa.d rm.ada
iiaga'm;roaowng)
bIL—L—IM1Na understand that if Me remains are notcle nhad withim 120 days of cremation,
(o.n.mr'+ ) Pine Vi C ro may dispose of Me remains in an Malawi manner
such as by scaftenng.
CRIERNATION COWAINEWUM
(�ONEddw ldbwiMl
An um to be used as a contamer for the cremates remains has been Wrchaxa from
Baser Funeral Home and is described as follows
INVe understand M81If the um Is on Small to hold has Mbm channeled remains, an a iddonel NO conbiner may be use el
his deeliJvery�.
n um has not yet Exn pumhexa. IaAN untleramM Mat if no um is pmcheaed or dMrvax provia po
Weather
P cord pFace Me chamaba remairw inergld hmppery
WntairerMdolmans,
This Aulhaieetlon Farm was phaviaed by mvwwre.rm.mm.l
was BxeudM at Vuml v wn mq Ralrrr mi Home
mM.rwnow..x..y 1l lalavelM SVeN Oueenah Nsay ri end is vgrea by Me fuxM director
as whose;t0 its eXBcuflon.
IhVa nave Roil a comPle ad copy of this Authorization Fonn.
The pennnts) IdenlRlea below Ialaro Me personlas) In control of d"Ition, who by aligning this AVModnlbn
Form,atleat(s)to Me accuracy and compim¢naae of Me Information contained in Mu AUMorbtllon Form and
eulbodze(s)fheforegoing.
signs MIS a day of -I � , m a0 .
Zcc.ne T� /
rmwae�.rea rvarm
av G ar Ski aa6 C Il 41143
.„.a>N.werv.,w aww
Adihw
Viliffbi
„md�wmrww dam.
� lm;
Us
--
a�.mm.w„yw,w�,mm.w
Fureral Moms Reg.:Y01130
w�
N. S
ppSrewia on, ovrq ,ywalMwwe nN3N3