Foehser, Charles A Pine View Cemetery & Crematorium
Quaker Road
Queensburyl NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: �FgKnOYp _ RETURN TIME:
DATE S TIME REMAINS ARRIVED AT CREMATORY: 71T IA1
NAME OF FUNERAL DIRECTOR OR REGRISTEREO RESIDENT DELIVERING REMAINS:
nvua � 1I es3�,Aea
NAME: CNR IIII WEry pD' CASEE R��I
TYPE OF CONTAINER: _ /LLF� ylL- LIMIL
PLACE OF DEATH: 30 II�I�{ (�_I ,S ( Gaday0 IlQl1
ESTIMATED WEIGHT OF REMAINS 8 CONTAINER 'I I'D (e
PLACED IN HOLD: �u-
PLACED IN REFRIGERATION: 4%T+ LYM
DATE OF CREMATION: 111101))b
TIME STARTED: I'ISPnLf TIME COMPLETED: I)EPh
PLACED IN RETORT: )' 30?m MOVED: Z.IO Pr) 2NDQh
RETORT # IN WHICH REMAINS WERE CREMATED: ��I�
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE "AN 08 HOURS P
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SHALL GO RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
EW YORK Division of DMI?µX OF.ryEMETERIeu
F cemmerteP
° ES
Cemeteries mmY12;11pOW
Iw� ,e»,.,aadaa
Authorization for Cremation and Disposition
This Acclimatization Form must Os completed And whined prow m Military M remalimfar Bn "on.
NAM: 0]AYI Nua fc0
CMOM1ay Name: Pine Nos Cremeby
Perms. 21 Quaker Rwd,Ouee ury,W l28m Phone: (518) 10SooP
CREMAMN IS AN IRREVERSISLE AN°FINAL PROCEss.
Crema W n is Cenral am by pMtlng be remains of tle deceased And life wmw Malay;tam remains mro a Minimal Member wMM
t"aresublededbinbneehealandfl 9 The Mat and flame will N mmM and consume e"ry ing onsoWne and msbl,
which am all Met Ads b"X after meta n.
Fakmne formation.the Oemabrywill Mae reasonable efforts to remold all of Me remains and other material hom the Mmadon
chamber, bNaeme,minimal dust Mat endue art such he MflbehiM. The continental Mat Inte lal and breige melmial form
Ian remains BM the InycemI and bmgn maWmi will be dVt of Me required by law. The mmaI remains will tea naAaniully
yaNavel Me small p AAw and preredInfo a desgnHM"Wimrorum, Cmma mmvlmpsmmilyampuMdWuMInO
MngklndmeMM nwpnblEla u vbMYl Xsaw.
OPENING OF THE CONTAINER
The Oemtldy,may only Open be cnMNer holding be committee human remalne In Gmlmd orcumslanwa such as N confirm the
idenply of Me deceased or to ensure PM no mmnal'is endoI wMN might Injure emoloyM13 or damage the crematory propady If
humvn remains are dtllwred In a container which Is nd summer for rnmvflon such as ceremonial or rental casket.Me
renNory will require Mat Me nmvlm ha moved am a suitable mentaNrt bsrore X accap"Me remains. The onal of
about ar Me transfer or removal At minimal all the conducted More a m and Wl As done I n Emory,with Mgnilyend nnsPod.
IDENTIFICATION OF DECEASED
Name of Deceased: Charles A_Foohwr MCMe his MaMed
Left mown AWreu W Mres uM, SMuylemAk W 12VI
Place of m 20 my 18m, 5Muylense Nv 12811 �
Sea: I7 M O F Age. 73 Doe: 08/28/1946 Dam Of 01NN2OW Egbmamd Might. / , J
remember of asMV ,nor in whi remains lint be de ered.
Cardboard Box wM/ooden Brae
PERSON IN COMROL°F°ISPWMOX
(Pemm�fal0"Mat ordis $o , M cm,or roe Mbwmgl
I arni are be dnlpmmd agenl of its deceased dmlpn k a will or women Instrument Mmmmd pumuanl b Public
Human Law Season Q01.
OAR..
IAM hence no knowledge Mat be dnxased exawmd a w n malignant brought m Public Haman Law Sel 4201 or
Mn Containing directions for dirPoSNMI of his or me minimal and gwe are the woCnum hal pnoMy under Public Haft Lew
$actin 02111 alp haw the rgMb euMorue vemaWn Mane remalne of Me deceased. WMurmkdomblp m taw deceased IBM
rollw
Charles A. Foehser
I DS-055 f 0m,. 0oFa0) Page t of
Authorization for Cremation and Disposition
ni(farn Me not beaw)
Normal 2 oescrlpoon: Pamela Fml (Bpmmel
1. Aperrson Asume ,wrung pursuamto Public Neal Law Semw 42o1(3)I
3. The¢urvMng apome,
L. Tic wN..ly comma paMer.
3. My mr,crg coin ergMaen y®re 0f no or older,
A A surviain9 Garen;
5. A surri sibling egMeen years M age or Older
6 A Imply appointed 9aN4n:
]. Any cereorm)eyhMn seers of age Or ol0er enWW W Mare in Me R and and lsbre Mill In PoactIor5Mp b Me 0ep3a ,
8. A duly appointed feudal of the area:
8. Adom trend or reelrve Min has foculsd a woman coal p romenl b Pools Nerdy Law model 41
10. Achuf fiscal officer of a Many ore ruble administrator spectrum pursuant to pay 5un09am's Cwrt PKKMum Aor
IW. My other Cron who is adin9 on behalf of th dewsaed eM amor has executed a wrliten tmprteni amen by Pude Heady
lew 8etllo,4201(y)
pG� B ALL MREEW Me b8aln9)
jy tMk hereby arum that An achy of Me destroyed May not contain a Nepal M"pack. cower all, W'Os live implant
d reduadmi order add bet any such museum,were command poor b Me BreaNm of Na Auffimarbn For Failure to remove
MQer[e�Items offer fir cremation may result In he cup W ba cmmabry and cremebry praonnel.
1�May aMrm NtllneWmlde have been Men b RMelend Gam. Hoag
regar in9 the remonl of any personal pmpehy,or Other Ming Of value which arty IVraon agmng b&ow or My fam8y nmlar M May
deceaxd W$eh prexrve. Plre Yew Crematory
Is net rwponeibe he the removal of personnel mayor poor Me cuneirer IX M1dn Ma remains of Me chased *nal Items ago In per
complains or wide Me remain will he destroyed by Me crerMtion presents and cants ba normal after cremal
Ixs✓ uWe real auModv Plre Yiea CRmMry
ammwcase
m Pamela the regment m the dmoned.
onaluut CaFmCn y
mm hereby authorise Me named hmral director to Proved for delMm b and mmation by an aXemaa
mmatory, H deemed Mode ry In the opinion of Me funerel of recap a nd to amend M 15 form to proves Me correct name a no
addmm of such aMmaa cramabry.
FINAL DIBFOSRION
to arson proposed m fomvd Me uemaad amam of for des WMom may ametgy w:
Name C pa ,onaMcumral Care
Mdrms. 4D3 Madder ACV.,Saint Ja Sprvpe. NY 12M Phyte: (518)SBYdB!<
The sensed sim of tom will or dary aasltlWnD-
40
Ifbr Brv/mvcn MepmnnmBd tmV dx¢nW ache pmssseiat olMB Oanead medic,
pvm Ywatrematpy Is euMa®d he 9"possess",of
Ma remains to p...amymm.r Cmpan'amb Fusel Cary.Inc py mAety
am In pmaon ter by repressed mad ch AFw
DO&18g4f Otev. Ml201 Avwnw Page 20t3
Authorization for Cremation and Disposition
l�e»m�rol
]�IMIS uncle bod Net it the nmame an ml caused within 120 days of mmmal
farm varm Crematory may dbpme of that mnain in
anlm0ievabb manner.suer rag as by gene . maxummahal
CRENIMMN CONTNNEMM
flak lONE am rdbwmgl
An um to W used as a WMelm for thw symbol handier Ma amen NrN from
and is denuded as foloss
WJe undenland that if ere um is tea smell b bold Ce 0A cremA remaiM,an assumed ruts mnbier may b u lMMiwry.
-0qR.
—Sa_Mum mn "t WrcMaM. IMbunders dmdifmumiepuM orothwrvrmsgoMes
Pare Vew Cramamry Will qaz the channel mmaimin
hapacmvvri
a edit min osmama for model
Rolland G. Hm WueaeorMa
ThisAWroNn4on From wed proMAMM
Commensalism Funeral Cam Inc
402 Maybe Pw., borough, Spuds, W 12M0
and la siby the Nreml diracmr p miNass in its execution m
Il have nreived a command oxpy of this Aumork Fomr.
The perform)IdengM below MASS IM panrms)In comrol d sepoN ,Who 4 apnlad MIS MemorkNan Form,aXesNe)
W era accuracy and ComplNeness M Na Information zonal In Nb Aumorlaalbn Form and WMohe(s)Na formung.
Signs dw m day of Juay m M
Phase Fceheermoor
__ 6T �a'LLa/
]II Myers IHM, $CN/Ierain NV 120]1
21
WITNESS:
Rdned G. Noa2
him mamwervrno m
CA A.Fcelna
WS109V(Rev. 0a120) Pg3al