Tennyson,Joseph Remington Pine View Cemetery & Crematorium
Quaker Road
Queensburyl NY 12804
(518) 745-4477 or (518) 745.4476
FUNERAL HOME: A(bIALUFR RETURN TIME:
DATE L TIME REMAINS ARRIVED AT CREMATORY: Wif to I'W ph
NAME OF FUNERAL DIRECTOR OR REGRISTEREO RESIDENT DELIVERING REMAINS:
DAIS ({Lt�
NAME: 12FAI TE`NNI-W 1 I CASE # 77.E
TYPE OF CONTAINER: rN En tHd 11 A IIeL
PLACE OF DEATH: HL J �(U t�511M I
ESTIMATED WEIGHT OF REMAINS S CONTAINER I ISS ly'
PLACED IN HOLDI
PLACED IN REFRIGERATION:
DATE OF CREMATION: y����� RTI AI9PJd"' L �� iLd
TIME STARTED: I I'H(m /'LR NII TIME COMPLETED: 9.31RTQI
PLACED IN RETORT: -I•QS AH MOVED:
RETORT # IN WHICH REMAINS WERE CREMATED: &A.LAP
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 4a HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE:THE CREMATION LOG SHALL RE RETAINED IN THE PERMANENT FILE OF THE CRIMMTORY.
Nice
Shire
Oepnment ofa5tsl.
NEW YORK Division of DIVISIONOFCEMEnRIN
yjtA o! as Comne,ee If...
OPPO0.iUN1^ Cemeteries N9mlAi
Y 1231,0001
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Authorization for Cremation and Disposition
This AUMomabon Form must be completed and signed prior to Military,a remains arcremaeon.
Dote: 0612746030 Number: -P'r
Crematory Name: Nee YIeW Cremat0
Aedmsc. 21 Quaker Rd., Queensbury NY 128N Phcne, 314-)gS-fy
CREIMTION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation k caned ml by placing the remains of tee dewned and Me wMeirler holding the remaira into a cremation chamber wMre
May ere augedeebIntense hastand Anme. TM beg and flame will incinerate and consume mMhin°ex bone and 1,
which are all Ma will be left after CmmadOn.
Fdlowitsp 8tgn,the Cremaary will fake reasonable afford;to remove all 0 Me command and other maternal hoed Me Cremation
chamM tut acme minimal dust anal residue will likely was"behind The crematory will aspaub mardendl and postage maknel from
Me remains and Me muderml and fomgn maternal will be disposed of as required by law. The cremated remelm will be mechanically
puHev4d into smell awards erof placed Into a researcher container or um. Cnmeadmmalnsgenmilyampub mwuMlno
slnglefrnmmtisreagnb $$akel$UplesUe.
OPENING OF THE CONTAINER
Ta crematory may only open Me conduct,holding the maemaled humanminn m limited circumstances such as to Program the
identity of deceased arm ensure Mat no materiel b extended"ia might Now employees or damage the crematory PropeM- 9
human remains eradelFrered Ina conminer Michisnasuiablsforcre Lion suchmce ormnleiorrentalcaske4Me
mnamry,will raltbtl Me remains N moved Ink,a suitable consumer WMmIlaumb the remains. Thecperna a9
=O ,ner or the transferor removal of remains will be conducted bekre a w arnalus and will be done In pnwary,with dignity and rasped.
IDENTIFICATION OF DECEASED
Name a Decreased. Joseph Remington Tennyson Mental i m us Married
Last xnonn Andros. 59 Art Tennyson Road, Chestertown, NY 12817
Piero of Deem Glen Falls HOepitel, 102 Perk Street, Glen$ Falls, NY 12MI
sex: ®M OF Age. 83 DOB: 1010411936 Data of eath 0812812020 Biomass weight 155
Descri of utkeuWMaine,in whI[h remains will N Mitsu tl.
New England Cremation deluxe container
PERSON IN CONTROL OFa SPOSITION
(Po (a)fir formal Ysluallon, art ONE of IN kN "I
drawn am Me designated agent of Me deceased manganesian a will or wri munumi executed number 10 Public
Ilmnh Law Section 4201
-0R(12
AYa he" had knowledge Mat the assessment executed a wnXan instrument pursuant to Public HmIM law Section0201 or
nlamingIdlrtcNns Air Me dlsposilian of his or her remains and Now are the Parthaving prnnW under Public Hmllh Law
Section
C201 and have Me rgbtlo auMwize cremation aMe remains of the deduced MylOur MMIOO$hip Mthedeceaedisn
faimays
Joseph Remington Tennyson
DOS-189a{tgev 00120) Page 1 NS
Authorization for Cremation and Disposition
(IRWHcawfI k$tbebw)
Number puuiption; Survivna I
2. A n &Sgro dIn wong pursuant to Public Heats Lew 5aUm1201(3);
22. The surviving dsurvivinges%pacer.
D. Any sur iq MAia eighteen years of age or doer;
0. Asurvivng perem;
S. A Maryland string eigmeen years of ape or older;
S. Ala lU prompted guardian;
0. A Any
pearramad eihteenducl rydlhOf Irges Or e able.older entered to share in Meestate and who la/are closest in reletbnship to Me deovased
duty 9. A dose Trend Or rNative who has executed a wfiden statement pursuant To Public HeeM Law Section 42O1 O):
10. Achief fiscalOr Of acoumy or a pi administrator appointed pursuant b Me Smrcgate'¢Couit Pm¢ ure Ad;
Hear My Other perwn who is 201n on behaff of Me dammed and who has Mudded a wnMn statement Pascal to Public Health
Law Sedion4201(7).
4(Inifi TALL THFEEdflre/aNdaki
IAbe hereby alum that the hat Ofeledeceamd does not Mnfeln a report,badery pack. Poaermll, radi adve Implant.
Or mostow ive de me and that any such materiels were Tmdved Por to the exeatron of A dhompas'On Fomr. Failure to remove
Mprior to cmmadan easy result In ham to Me Crerrlamry and cnmMry Wmnmi.
INe affirm that instructions hove been Matson m Da�vitldAlexander
regarding the removal OF any Mel ll proPoM or Other thin of vi which any pemn signing below or any mmtly member ofthe
deceased wished to pressure. Pine View Crematory
w red re¢pcnsible tar the removaldpersonal llama M1om Me conmineror lmm Me remains mthe deuaaed. PoF libmslehinthe
NKKOrWMthe remalm willbedes4oyedby Macmmed p�sandcanroberemw" Aermmadon.
vMe hereby adhorw Pine Nlew Crematory
w w
to creme the rem.Ina of mMaom.
Ildfiar DPnnrvny
Vwe hereby authorlm the named fill director to provide for delivery to and cremation by an adarnam
admamry, M, If deemed Sa ry in Me opinion MMe m nd nomi dlnr,and mcea thin cane and form to provide e caned tarts and
dress Of Such ademem crematory.
FINAL DISPOSITION
The Paul adhomed to receive the cremated remalm OT the dewawd M1wn the vematwy is.
Name;Alexander-Baker Fenerel Home, David Alexander
Address: 3809 Mein Street, Warrensburg, NY 12885 Phone: (518) 823-2085
Then Md rNnalM Or demai will M dsp080 d as ellowa:
Return t0 family
If tar any mean Ge pram fumed above claw M dke p emm 0 Me cmmaW remains,
Pine View Cremaory Is support t0 give ppasazzion of
the mn roam Alexandar-aeker Funeral Home by tlefharr
la.w+wmae�w
in Pomn orbs regNlneO man. JosepM1 Remington Tennyeon
fteftecommi
MS-1Staff grey OMMO) Page2 d3
Authorization for Cremation and Disposition
(tlnr�gasWngl
VWe uMgelantl Nal RMa remains are nm ciclmed wilM1in 130 days dGenNlgn.
Pane View Crematory may einpoae W Me eemeaw in
anmerrSvable interest. such as ray scattering, i
CREIMTION COMAINERNgN
(�I ONE of the lWwvnp)
Alexarder-Baker Funeral
M um to be used as a container for the concede remains M1as been Wrcbextl M1am w.....e
and at deecnbN as follcei'.
MeuMenundtlwtiftI umisMsmalltohddtheentire G6Ma remains, anaddnimalegosmnrniwmayWu f WYvery.
M um Is Wyet purchased INJe Moderated Mat it on um is purchasim or dhennse prorated
Pifre Ylew Crematory, an place the camaim remains in
a....o..w.n
a Mid krrpxery mntamer for delNery.
This Authoritarian Farm was democrat by David Alexander sea executed at
Alexander-Baker Funeral Home
3809 Main Street,WarrtanaWrg, NY 12885
and is signed by Me Nneral director as ahead toils exemtion
Me have remived a compmMl fare of this Authorization Farm.
The panan(sa rtminbt below Ware Me paraonls)In Mongol M tbposltlon,who by signing this Auffromm tiara Form,afthri
to tin accuracy and denomnmµs of the Where lion wnbined in this Authentication Form and authaangs)the foregoing.
signed any 27th day of June gp 2200
Kathryn T. Smith
ame. ...... r-
71 Aft Tennyson Road, Cheaterlbwn, NY 12817
WITNESS:
Davitl Alexander
4,
1003A onwewmn
Minna
Joseph Remington Tem IrwMaaaaam
DOS-18984(Re, oa60) page 3 of