Julia M. West Pine View Cemetery & Crematorium
Quaker Road
Oueensburyl NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: IJIf Irk _ _ _ RETURN TIME: AM '/_ g- q 'aNM
y� f
DATE S TIME REMAINS ARRIVED AT CREMATORY: . S 6—
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS: -
2 &�
NAME: M ( q EI 41P T< CASE V T (5
TYPE OF CONTAINER: a cx�e c-o''// Ivy /r 1 w 1 kpaA4 IYIb✓�n `r A
PLACE OF DEATH: _ yy CLJ µ'VI &Wd =rA d }n/ V
ESTIMATED WEIGHT OF REMAINS S CONTAINER_
PLACED IN HOLD:
PLACED IN REFRIGERATION: /
DATE OF CREMATION:
TIME STARTED: -/A- TIME COMPLETED: �2
PLACED IN RETORT: _ MOVED: // - /,( 3^
RETORT NIN WHICH REMAINS WERE CREMATED: -5Es&Lepr 1pf
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE:THE CREMATION LOO SHALL BE RETUNED IN THE PERMANENT TOE OF THE CREMATORY.
1 1
ORK am ennomm w
NEW Y a sum
Division of DWIMNOFCEMUERIES
STAOPPORTY" Cemeteries a°:,�,� ^= _
Tan ...1s18147ems
Authorization for Cremation and Disposition
sea AWndlaaaon Faun muH No =nmpW%d and imbi poor denvary o,rim uns for uxnaUan.
WE: July 10, 2020 Number 4/Y13
CmmM Na /: � R IxJ 4f,ne(0Or
Mdm : :i rµ� nger Ent oul WAL� 01 jiaOY Plgp: fete) nr-y��
CREMATION R AN IRREVERSIBLE AND FINAL PROCESS.
Cy@m m is wiled oN by half Me remains M the de wa and the MeaNv bkNng the remains iMo a aanSlon Gamer where
They ate aubjecum minlmes bed and West TM heat and flame will lMimms aM consume ewrythlnp e¢epl bone and mell
which are all that Mn N lea aM1a cremel
FdICMngV MIM,the venall WII tape fe unable dtons to feltwe all OF the Mans and other naknal bum Me mammon
mamba,bay was minimal duet area reaidue on likely be Me behind The CFMWM tell separge incidental Fred lontign mMaih Itan
the M®m ad IMincgmbell and mrelpn malerle roll be disWa Wbyha Why low. The aerated Meim will be mNla
pulvedaed Mar small glees and pool Into a des'gndeal orminefor um. Cnma"d nmalnsomrNly an pulnr4 d uMll m
4ngla fnpmm h,MN needs was Radical tissue.
OPENING OF THE CONTAMER
The mm Wq may Way Mar Me consume holden;the umermWM human remain= In limited on(metra e n each as to OMrmm the
Nobel of Me Or Wall that no mMwal is encoael whch might injure employee or damage the crematory Foral If
human Maim,are deliwmd In A m,ftlmr wM=h to not
mullahs tar marem sal as comment at rental casket,me
crematory will require mM me monalme be nwwd Into asuitable conRimr Wore It accepts We Femme not. no a ,NOre
conb'nerM ma transfer W Feneva of mmmra will W PoMumed behorea wXmsa and veil be cone In pwary,arm haterty ntl ormar t.
IOEMIFICSOON OF DECEASED
Noma M Dammed: luli.l M. West Maital Shous'. widowed
LANIKAM nAddress'. As r1W, Will PA Pi Ann MY 3 2827
P m&mwh: same as above
irm, DM 13F nge_ZL.L g: 10/28/1944 oats MDeem: 07/10/2020 Esf Wftth mL
om nMcmkeNmmaNer In wham re mwl as hired. Florence Casket Co.
wood, woodcomposite base, Cardboard top. -
PERSON IN CONTROL OF DISPOSITION
(Po/ml([)in sMMoldaWSIM/t. mi11L Q4ENMe I�in�
I aMVe are IM desla W aged off Me dceaaad d59on In a vAl Or vstmer instrument eaaNad pursuant to Free
Hyl Lax 54Wn<201.
-OW
mIM1Ye have m kn`xl_4gelhal Nadereaaed e=culed ewnlbn inlrvmml pursuant in Public NeaIN Law SegemlAl in a
will mntsny direcomy for the dnmei(vn of his or henemaim and Vvre ere the p on(s)haver; hichur uMar Public Hmlm Law
Sm,on4201aMhwethe YgM a zeuamationottheremamotme09C OF Myleufrelatonshlptomadm n"leu
follows'.
Jolla M. West
OO&tSSblf ev.011 Paral
Authorization for Cremation and Disposition
IMaml Nxnhhe0lbalow)
Nummr:l oe[ulpwn: anal/
1. ApNeon demnded In wring terelwmb Pubmtheadl Lex5 Mainly:
2. Tlbsur,,mgem,ml
2a. TOe surviwlp 0emand pother',
} Any whoring child pgMM years d We of doer.
A A s�Mviie,!arch,
ry wgMecn years d We or ONeC
6. A wit mo idled guardian:
T. Any lwvsoXs)Ngmem talent Of We Of char MlroeG to Sham 11 Me NOe aid wen!,love decal trial to We Moment.
A A my appdnit 0ehl of the delete.
S. A date mind or carer wan Na exmlt a when elalemell command b Fudb N Lax Secllon eNl()I:
10. ACMal d,ml ofed,of a aunty or a pubic tmlnubab Watched puwNl b Nan XMIna'a feud Rewdme act
10 , over other pah[m who b ald,ng on behalf Wile oxeast and wan Me exe W a wane stalemenl pummel to PWllc Heath
Lax Sedlcn 4201(7)
G�ff AU THREE o/Me th rmal
®y/ V(_ Am hMeOy affect that Me body,of Me dsmM dos in northern a marry.emeary peck p>xm Call, 'incentiveImpler
or radaadtee device and that any such cabdal[xae mmnvt plo d Me exwlen W W[AuMwhaMon Form Free b remove
tlwae Ibma par to uamplon may mult In harm to the emmalwy and uemalory paraonM.
SIAYe ldrm Nall aaWdan[nretetn glum tp Bruce A. Masooa12261
repardy the demand d my personal pmpedy or Other term d home rich Say paspn agninp bed✓or WY family member a me
pay Vylat
u wl rnp 5,bM for Ue remmw N Cereal hems hem the mnlarer w from an remain W the demand Mohamed mum,Mod In the
chairmaned or Am Me remains All d de¢boyt by mee(t]hermal praeat et canna be removed after cremation.
®&a) Me hmmYy Minnie
to drab Me remWa of the demand,
FINAL DINNOSIRRION
The thud authorized to owned n vemMt remeart W they d%Wt feet mar Oem a:
Narq Bruce A. Mason
P.O. BOX 277 , Fort Ann, NY. 12827 Phtm: 518-639-5252
1M UBmYt remorms W dare All be demand Of muwe.
Return to family.
If lw My ter Itoval namd above Mrs M time pae[mean W the amnut re s,
a alulwbed to pan mwmtb.m
Its demdmto Mason nF� 1 flOm Irrawaddy
mew
In Reveal w by regelmt real.
Julia M. West
Doll(Rev.09115) AwmomM Made 2W)
Authorization for Cremation and Disposition
IM^a'I merarowlnm
®1J!✓Meunem3 thM,I"reIlnsareMdWme] Nnl2Dbysorvema .
�vV U maddisWsed"amamin
an moral ml such as M the". "Mein
CRE"MN CONTAINEnIDPN
(/Mp/i�JONE d Me bllawal
®l An urn b as used as a wntalnel lm Ne consent remans has Leen WlUa¢ea M1om Mason Funeral Home
and a dasobad as ronows C!!L�'r[REG A8/LF ArF ns///L/f;w=&yM OpQ
MO amended got f the um Is ba small to had Me ctire wnand Mor it at addl5atal held barren may 0e used for defil
QP.
An um'a Nl y&WIMasM�JIAl understand Man it ro um a pandroed or consent mordent
d.�IAu Mi Obee Me real remains in
e rgia Several coastal far dnner. rerm�
TheauMOWal Form was mo darE by Bruce K. Wagner 12261 was annual
Mason Funeral HOme M~tam
18 George St. , Fort An 827
and is where 4the huml directs as amusing N mumalroe/arrK
Me have m.Xi.M a pmgMed mry of Nib ANzatM Form.
TM Porsonbe rainabhad below ai am pnodsl In barrel of baseball who by signing dials Ambassetbn Form, atbsllel
b the accuracy and cwnpbbress of the Inlwmallm badear dIn MIs AUMoaheNon Farm and wNorindlMe rents ng.
Signed thin, 10th argot July .2020
®,e msRL✓ r fCW i
dvard. MY. 11"Is
Ass, —
'
NTNFAS:
rc�.+ Bruce K. Masonhennaed
lFea.r��artt uM
Julia M. West
DOSA09&1(Few 08115) Pa]e3o13