Looney, Tanya Marie Pine View Cemetery & Crematorium
Quaker Road
Cueensburyl NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: !ACgw RETURN TIME rI...DATE & TIME REMAINS ARRIVED AT CREMATORY: 413pl'C 1: fi�A Mn
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
.�w�� hn fl' A
NAME: IMA /LouLq CASE # n%
TYPE OF CONTAINER: qPF: ('11� RM N ( Am(dars�
PLACE OF DEATH: M r IS W Y1 Isl 1'
ESTIMATED WEIGHT OF REMAINS 8 CONTAINER T`' Ur
PLACED IN HOLOR '
PLACED IN REFRIGERATION:
DATE OF CREMATION: _ 412e 1b �yI
TIME STARTED: 103NAh�rI TIME COMPLETED: I DO(I I
PLACED IN RETORT: WfoAfl MOVED: ) An!
RETORT # IN WHICH REMAINS WERE CREMATED: 10iu A11fE 1
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CROMATION NOR SHLLL RE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
Department
or sine
FEWVORK Division of DIVI*IO;GFCEMETERIES
aTAn eaMUC�mOemV,Iaz`
°"0R1VH1TM Cemeteries sr 0001
nr(51In4a4 6226
Authorization for Cremation and Disposition
This AUrbanization Form must he win limited and sign" prior to Mllwry of after days for tree Won.
Deter 'Put 1210 0 Number: Tit
Crematoryflame: Pine View Crematorium
Address. Queemetury, NY 128N 11 a,mv O R aO phne'. (518)745 76
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Chanatheyeeon is re subjected trio inns heat and flamebacIng tie ns of the The The heat and llama wilscounted and l lncinitrate and djainer unu ewVwyyj e;e remains Into a etvq bone nd chamber
mebl.
wnicb are all Mat will am left after rnma"on.
Following emamon the tremalorywlll take reasonable eRMa to remove all Of the remains and Other material from the What
chamber, bid mine minimal dust and residue All likely be left ben'md.The aematay Atli separate incidental and foreign maenel"in
as
Ili The
the reran s and the e¢mall worse a and wE end a designatedn material mnlil tom beer osed ro n.Lnmeteemined d remains gammily are PuN•rWd uMl no nommones well be
puv gem
single�Ire9meW ro recopnlrabro vs ek.Iml n..ue.
OPENING OF THE CONTAINER
story mry Dory open Me how
fit the umvemeted human remains in IImI1N drwmnanwa,such Am W cenFvm the
Vlefitlry W Me ado ¢etl or re that w materiel is embsed wiidt might injure employees or damage Me cremetary pmpeMH
home remains are"livered m a container which Is not suitable tar cram aeon such as ceremonial or r•ntul tJ¢bt,me
maWq will owed In that from mmalas ba mowd Into suitable tonmMr More It acwpta Me rem saw.The Opening of a
consumer Or the transfer Or removal of remains win be Conducted before a fairness and will be done In priwq.win dignity and harbor.
IDENTIFICATION OF DECEASED
"omeol Demesed. Tanyaliftedirriumana MCMel Status: Single
Last Known wares": 69 Oak Stteet Hudson Fells NY 13839
PleceofD Glens FWS Hospital 100 P ASt Glens Falls NY
your M [] F Age'. 45 D0@ 0=911974 DaMOOeelll 06O 020 EWmeted Weight:(2b
DesvMtbn of uske ntntt In wash remains will be co ivern.
mp,.{.A)ews CYc mo.J-gag. Case, 1J�y "obi 6ArFamf irar lhowd 4oP
PERSON IX CONTROL OF DISPOSITION
forest
in WIV ddapoveon, MIIIaI ONE oFfMkWbw
I emMe are Me"agn8 d agent of Me asceesetl moderated In a all or written Instrument emMed consent b Public
Hamer Lew Section 4201.
OR
love have no kdowleEge that Ne"coved eceCutn a Miften ummument porsuam 0 Public worth Law Secion 4301 Or e
rob t ,mN tlbeGlns for dispassion Of his or her remains and lain are the peMnP) mining p"dty under Public Health Law
SedIn 4201 and new the teat,to aWborize CremeLon Of Me remains Of to"ceaW.MrOur MW DmMe to Me"woad is as
follows: Tanya Marie Looney
Memn•oxxsea)
DOE-10961(Far, 08115) Pegeltf3
Authorization for Cremation and Disposition
(Inert hwn alp 4W6elowJ I
Number 3 Directions, d a bA a h� e ✓
V
L Apmaon Cngi sperm In urlllnp pursuant to Pugic HUMLew SedioMP011a);
21 The surviving domes:
L. Am survi domestic ennyn
3.A Asurvivn In parent,eighteen years Clogs or Older
g parent:
a. A aurvvnappoinpegNeenyears Mega or older,
9. A hawfully persms) eighteen
were
L Any duty mixtures
ixtures Weee years of age
st or Older entitled to 9NrB in the estate and wM1O Ware Go¢e¢I in relationship to the tlew¢q:
8. AA chatm and onelBtNe who Whatley of has executed a When stelemeN Wlower to Public Path Law Section O201 M;
m A chief fiscal cmmr of a course or a pu01b administrator appointed pursuant to he SLMOMAe'S Court Protestant AG;
10e. Any other person who is acting on l»nSx of the deceeaea and who has switched awnnen statement pursuer to Public Ha.w
Law Section 4201.
(bltlal ALL MREE Wane blkxmp)
®=L INYe hereby Whom that IM body Of by dememad does not contain a tommy, hatlery pall, power call,radwNve Implant,
or radioactive devim and Net any such materiel¢ware removed prior to IM eaewtbn of this AUModaadon Form Fallumtoremove
Mesa Items Porto emmedan may result In ham Wo mamabry aM comrtory personnel.
� IN✓e emm,Nm M¢truSmenavelmmplvenb OONEENS NIKAS
regari me amoval Of any persmd primary or offer Ming of wu ,which any Mason signing bells or any family member of me
decaaeedaveneabpreaer. Pine Vew Crematorium
or ran responsible forme removal of personal hems from the contain or from the remains of the demesed. personal Items left In Na
carmen or with Na massive miff be destroyed"a crema0on prooaee and can not be retrieved after cmnation.
0—CLINh hereby arnhorize Pine Vew Cramalonum
W emmab the remains of me deceased. �
FINAL DISPOSITION
ane ewneum ze m blossomy oemmed remains ofthe drommeal%mMeoemabry Is
Name: S� u 4-P' r 4r C3-i 1 e rfr , TALL-
Mom$$ (irk Man S6 ✓-1 F6JSM F () ,p(Ad All 518 - 7y-f- u>.u3
The canabe remtiro of de¢ewd Wll pre disposed of as folMo: r
It for any reason Me pool nerd above does net base Malawi M me connoted remains,
Pine Vewme Cmmm
rer i riu Is.NhMZMIopMpowe&a1W
tlw bst0 bydalmmry
rw.", mw
in pemon or by registered mail. m.n
Tanya Marie Lbbnry
m a
WS-111984(Rw. 05I15) Pepe 2 Of
Authorization for Cremation and Disposition
(I a) sancta l
OTITi/li We undmsland mar it the remains are not claimed within 120 days M cremation,
Pine VBW Crematorium may,drimme of the remains in
an IChannel manner, such as by sastladng. I"^"°ra^"wn
CREMATION CONTAINEMURN
��
An um to be used ae a Caro finer for the Coal remainsM been purchased from
and is described as Runway:
IMIe undm&md Met if the um is too small A hold me eMre cremabd remains,an atlNdnul H90¢ntalpx May used for delivery.
-OR.(
L An um is nmyetpurchasw, IMe understand that if no um b WrMned orathernme prondedo
Pine Vew Crematorium will plw the cremated nmmns in
a dgd temporary anbiner for delivery.
This AUWodanlon Forma formal by DONEENS NINAS wea exewtedM
m Cadeton Funeral Home, Inc.
88 Main 51., P. O. Box!] Hudson Falls NY 12839
ep
and is signed by the Al din ctm as vAness tore execution.
IAnd have read a rempl&ed way of this AuModzatlw For
Thus prrawma) iderefied below team the "Moral In Carl W disposal who by signing this AUMwlntlon Form,aMe s)
W tho accuracy and computational of the IMormstlOn Contained in this AuVa,Mddl For and aumomMdz)the lOragoing.
Sigr//wdd ims lT Cases June 20 �20 l y2�r'lnu � Qy A6IT
4 oh; can rra cc cj ! R8
m�da..nwar
maran
W1TNFs8: i1 D
DOIINE,,E^^NS Nill
Tanya Mane Lmn
eay
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