Silverman, Rosemary Pine View Cemetery & Crematorium
Quaker Road
Queensburyl NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: 091V4L RETURN TIME:
DATE 8 TIME REMAINS ARRIVED AT CREMATORY: WI I]O -I,nAH
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
en ftwiut
NAME: 1?05EMK,4 fit"WMIJ CASE 10 -M
TYPE OF CONTAINER: hic a4l ,1� p I1���fR�y.
is FLACK OF DEATH: ! tw1 8D
ESTIMATED WEIGHT OF REMAINS & CONTAINER Ix AT
PLACED IN HOLDI
PLACED IN REFRIGERATION:
DATE OF CREMATION: LIVIRI
TIME STARTED: Y:OC AYI TIME COMPLETED: i0:10A11/D AYI
PLACED IN RETORT: G:bAR MOVED: 9-WAMM . y N
RETORT A IN WHICH REMAINS WERE CREMATED: ,
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE:THE CREMAT40N LOG S::u1 BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
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"MORK Division of D1Y1SOH°F�"„a�
p°PO"iVN1tt Cemeteries
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Authorization for Cremation and Disposition
This Audertraaon Form must the complained and signed penalty ceNvary afrmnatns Interested.
Date: Number. —M
crematory Name Pine Yew Crematory
aWker Rind Damnedest. W 12804 519-7454471'
Address. Phan:
CREW N U 4N IRRENERMOU AND FINAL PROCESS.
Cremation is earned eN by pacing Me remains or the deceased and Me mnkmer hobing Ne memorial a reemmmn charter sttrere
rnry are subjected to intense heat and flume TM Must and dome win inOrerl Met consume scattering Hcvpt bona a"merely
which are all MM MIN be left after crMNon.
Follown9 menMion.Pemachinery will take reasonable shade to means all of the remain and oMer mate! from Me aema(n
MMber, but name minimal do%antl rescue will likely he Ian bMind. The crematory All separate ircMemal and fici maternal for
Me remainantlthe promise
alandforeigno amowillto tllspoud of esr Cm by law. The w""ll remainswill be lie $niralty
pulvaeed man smell pares and plated into a designated coMainef0r um. Crynuhtl ramaine gmMlly vre puluerlutl until no
BirgN IfdgTeM Is recognizable p Bk0101a1 tlyuv.
OPENING OF THE CONTNNER
TM chematwy may,only open the wntasher her the urvGenaed!human remains in Ilmen d ureumiUnme, such an to confirm the
identify of the demand or to ensure that no material is enclosed which mgm Injure employees or damage the crematory property if
human contains am deleMd in a container which he net su"abN Bar cmna4on such as ceremonial or rental casket(Ne
mabry Milreguire Mat Meremainsbemovedin aeufbblemntatnwb mftac Mfinremains. Theopeningofa
¢nteimrwt119 traneltt or removal W nmalnavnll be oaMWetl belwe a vMlgea aM WII be dma In plivecy,weer dignity antl reepetl.
IDENTIFICATION OF DECEASED
Nam odlymmased. Memel Status: wam d
tan Nnoan neerem: con front an Own NY man
Plmw of Death. Fort Hudson Nursing Home,Broig way, Fan Edward, NY 12826
Sex: OM i9F Aga'. BB DOB: Voorhies DWdomtlr d'mtt, Elematetl Weight r
Omaiptim W pekeVwrrfeirrer in wTiG remains will be delivered.
entered Cmwm',Mlle rarehaere.m Inwo
PERSON INCONTROL OF DI POSITON
(Pemm(s)m Wheat W mapcWlM, in"ONE dflre Agen l
enMh are the designated agent 0Me dNeeud Membranes 0 a wn awMen instrument exeuded pursuant to Public
(�H�x$M�IaSoldier,w Soldier,Q01.
ik� INh race no knowledge thin to dMesed executed avrhen Instrument pu tinum to Public From Lae Baden might or
sell wmaimrg Mregbre for the remember of his or her remains and they are Me parsm(a)having pn0my under Puak Hearth taw
Boom 4201 and have Me hill to Andrea operation of may remains of the deceased. WhOur relvtlonship to the acwed is ae
rolwwe
OOS.1e9e4(Rec. 011115) Page I of 3
Authorization for Cremation and Disposition
rnB�aanha
Cream uneertivM Net time ama'un are nNclaimee uitnln 10 aey9 acremetlm
Gems a
ws.d� ) m.rebposadMam amei.am
an vnmevaeb manner each w by MWng.
CREMATION CONTAINEWIIRN
Op(p/(ONE NNre MImi
An um W M Amid as mTairo for the i emMee remains has been pwtluW from
and is desmrae as address
II uMwdend Mad if Me um is Was"I to M1dd the move cremate i mna ne,an addNonel real wMmner may Set same br%fray.
An um 'rs rot yelµrcXeaae. d uMaedabtl Rnoumispu awdardXenvisepoui
remadory
Air place be ammtlW rem ena in
p...do....n
a rigid temporary container bar calvary.
Patricia Miller
The AuMorrsation Form was session by was emaph d at
nawwm.mw.x
Brewer Funeral Home, Inc.
24 Church St lake Luaeme, NY 13814 u"w�"Viv1
and IS signed An the Nm'al eireem as smese to iW manager,
IftVe have remains a OTmpMad copy of this Aud Hma Farm.
The conotes) IanW" brow iehn Me persomm in coneal of dbpoeMon,who by menlne Nh AuMoriwon Form,at s)
Ni Me&%urmy and camplabness of the InlmmvNon aonblMe In NCB AYMWI Form and vuNOXmts)the brpW�p.
Mgmeal this or drwoff�' M
rasr,. m. ✓a+e
RmNwranrevwv.aieumss NHYtmw
..o-a>a..ehw. api
WRXESS: '� a m Vu.vnmmen�wu.l
PMbs Mass,
12m85
mI
DO$-18e$4(Now, =15) Page 3 of 3
Authorization for Cremation and Disposition
pmmr rrom dw ua n.wwl
Nui 9 Deampaon: Eli
1. Apemn designated In voting panoramic Pulsed HeeM Have 3edbn{IDit3tl
2. lines summing somme:
U. me summing domestic canner:
3. Any surviving sign eighteen teas of age«meer;
e. Asumming parent.
a. A eumare aiming eigreen yearn OF age or olden:
S. A marfmro appoimea gomdlan
T. Any penoam)segmmn rears of age or older argued A Snare In the estate and ram ✓are modest mralHkmamptoIm ore:
a. A duty appanal Milumery mNe mouth,
9. Adome Mend on relative who has evemcM a mtllen statement Net to Futlic Health law Shim 4201 m',
10. A War fiscal ottic0 a mumy,Or a WW administrator spas rand Wnuant W me Surrogete's Court Pnm]we Ad;
1". Any Other amem who IS edong on behaH W the demanded and who has Yeamd a anden agreement puuanl m Pi H¢NM
lbW$Bmmn 0201(7).
/y/��y�ryryp'/�ALL THREE af Hre/pMxnq)
1 \ YJI VIVO hereby ads=Mat the Andy W Me desred does mad Wnldn a batmrr, beard,pare,dower cell, rachacBue implant.
or redimadive device and Mal any such materials arm removed prior to the erection of this AuMakatl m Form. Failure m remove
does Mend;prior to crematlon may mayor In harm m"cnmat and comabry personnel.
PaOitla Miler
Ina amen ma lndwcam head heaneNenm
eymdmg to mammal of any terminal in �pamm�ertheme;of caw stare am canon signing nalwaor any family mamlser Of Me
dmmmad worries to madame.
is not mdpendinle a the removal of person✓ham;farm the Wmmner or from mremains Of the damaged. Personal soma lead in the
donminer orwilm me remains are ire aderarrdd any ands crem.don W««s and canna.neadervard after crenart
Flare Maw Crematory
( ITWafinelsr dream.
a cmmala the remains of me demanded.
F Nu D SPOSmON
the peon Marred to mangwtlro a en !angina of Hear dismissed Man dire vemehey u:
Braider Fumnl Ham. Inc.
Name:
24Church Bt. Lake Luzwro.NY t2ab 5fafif&2Fa6
�OtOOO Pane:
The CnmmM remaim a demaveY will des dim W sed N as loavn:
2
ruonrwlmvamyvv+msquprr�nmyalmauses
HKK any reason IM peon named save di rest lake peuxaKn OFMet/ermbd dermal.
PIrc May Comore, Is euHiaiaed mpew POs s*nW
the remains Breyer Formal Home, Inc a by delmey
in peon or re9m&ered mde.
morrey8lwrnw
o..sapv�m
DDS18gad(Rev.oW15) Page 2 of