Decota, Gregory Pine View Cemetery & Crematorium
Quaker Road
Queensburyl NY 12804
(518) 745-4477 or (518) 745-4475
FUNERAL HOMe: 86tl_._�. RETURN TIME:
DATE B TIME REMAINS ARRIVED AT CREMATORY: 711)1 ]O CuO�
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS: -
r1a 1u o __
NAMIH fyg" F—Oml8
CASES gI
TYPE OF CONTAINER: Flu a O {Yd� /I _uT"a(
PLACE OF DEATH: 231L CASL �d1 6 tI1. RI��/ 17
ESTIMATED WEIGHT OF REMAINS IS CONTAINER_
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION: 7�/IIitO
TIME STARTED: 7'16YiH TIME COMPLETED: I-jB At
PLACED IN RETORT: _ 7,V9 1 MOVED: 4 kf Af1� 9.4�
RETORT Y IN WHICH REMAINS WERE CREMATED: SWh4 FN.L,L {{iQ
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SHALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
Now York mum
TAIM K Division of DMM OPCEMMRIIM
VEPoR VI nY. I Cemeteries """.:"'
TOIa w' RIM4N 22a
Authoriution for Cremation and Disposition
IDaaWpn' OnForm must be compleM1tl and s igned pnorb del lorry or remains rornerranon.
Dale:071104201
Number_
Cre Wq Nam: Pine Vase Damages
pdp�, 21 Qmkw Rwl OuymWrY NY tRBM 51&]JS4aT]
Poona.
CREMATION IS AN 1RRBYERMBLE AND FINAL PRoDes".
Crematan re rams oN by PWO,MY remain,m Me Ueof and the remain bolding the remains Inle a oxnehat chamber whom
ltl.vareslrEjecladromknse lgatand nano. The del and flame will lMmeM and consume avnydlmB sasess b and me i
Which am all that will be Its aMr cmnatlon.
PoIIOArg crsrichop Pe co mMory will Mke mwmbb eMN to remora all of the remains and other matene room tlgcrtmaEpn
chamber but some minimal dust and :in
will likely be hart behind. The aemNory will sePorme mcdentel and brelgn demand kern
the remains and mescalanddesign occurred will be disPosed ofas rpuirad bylaw
the vYnated remeinsvnllbemeNwirdly
all
small pieces and placed into a dmdgnaled dmwwr as um. Cmr W consume penaMlly am mMdv eim MgN rnpmem Is recopnlvble as f MMMI Xu W
OPEX NGhe CONTAINER
The rl0matory may only open me container helping me uncremaoM human remains In limited awmspnces, such Am a mom me
iden4ty oltbe dewased or b around that no materiel is enclosed which migMdnfure emplowas ordamwe the crematory pmpedy N
human minor" am defended in a coMaMar whim If nun salable for cndmatern such as cenmontal or rain cmkM flak
wmaloerr or line cansfar orrremgal W mahoodwmy c rndi cekce a wlimess and w'n serum i n pm wiffll dle�6�rcueeapm[
IoexnPlcnno, N �oF DECP. F
Name of Demaml: OrPoOry Wary MaMeI Remain Marred
Lest Known AdlreM: 2312 Coach Rd 10 tYfq Arabs, NY 12509
Place of Deets: 2312 Comm Rd, W 12M,snake NY 12M
Sin: ®M OF Ape: 72 D08: O7106/1948 Dear of Dawn O7/092020 EAmeMi V.4gM 2OO
Description of wskm naimr nµdim ndmems all be dehwmd.
Florence Casket Co. minimum cremation casket (11111010011 wnugal cardb0aM)
(Parson(al Wff ION
in mltP a CONTROL rol o�dla OMr were ONE of Me answered
I amNA are then mEgnaard all of the deSaud dggnated In a will or%Much in&numeol memard punuem be Public
Human Iew SeNon/201.
.rM
INA haw n0 Aewwdga MM the d 8p 0a a mi dmNanent WnWrd to Pubm Heeat Law Sedan e201 wa
WII gininp direcpona No Ow Myocardial of his ar her remains and line am Me lNrsmis)baling pnoey under Public del news
3Mpn a2g1 arA heal then ryM W aulMkecrwnadon otMa mmema olthe rolrow.: dema9Yl, WMur"Vomhlpb Me M nosd au
Gregory Dei
D0s1ffii lRer. Dar Pagal
Authorization for Cremation and 013positlon
lire der mmeumbemw)
NUMb . 2 oe¢mpoon'. mawrumne¢wum
1. A 0Yyn in wMbg punuaM to Puts:HOam Law occon@01(3)',
1 ma sunning apoue:
m. 1M scoving colonel wmmr.
3. MY amrrvirre the Id eighteen ye0n of age or olden,
a. Aeomal WmM.
S. A aurviWg sibling eigMp yeas,M an m ol0eri
6. Alewlully apwinlOE goal
T' MY pemcMal eighteen older of age as older emended Mare in the e and"a Were tlWtlln relarwaship confederation
U. A duly a S. A Nam friend or r0ated"mfees egayhE a wnXen grail pu recent b Public Health rare Smon 4201(e)',
10. A¢M1gt fleWl o/Rrer of a county or a road connector apPoinbtl puvWM to May Steel a Court Procedure Act;
1M. Any other person who as efnd on half of the tlema¢60 and who M1m evpubtl a wMbn¢Irmont pu9WM b PUMIC Hall Low$ed n 0201(]1,
y( (1111 THREE 0 me wh ingf
/_J_(j_ INJe hereby afirm that qe hWy altlp Eeya¢eE ENe nee mnbin a henry, paXery paq, puaerwll, Merwao impNM
ornrearearve device and 1had any si maMrleMw mmmo prior added embut Mmie AUNorYa Form Fenunbnmaw
Mesaa�Xa $prbrto common may nwli In ham m 1M cnmabry and crematory Ponna01.
/ // // IMOBfin mR Inahucdne M1are lBen given W 3re0M1anie A Gilman
crowded tlm renwal M eM per m pray,or Meer thing M rebx Vol i aM person honing bekw or arty bmiry ma rofMY,
O a¢eb msi b pra¢eM_ Poe New Conser
m mlrworoibM brNe nmovel o/Porenal trans hom no mnteiw ww Panorama,
roman¢of May tlem y. Personal ) Sbe In the
�onlelnna as wee Me nmes'wil I he tl "Yed W IM cnmaBon proton add wnnof Be n "d after ethanol
M L�lMb Mnhy au6nrlae Pme Vier Cmmffiry
ms�r b CremeM the remains Of do od.
11 MOm 0GTIpVAL)
wom do
adMabry,XEOcoed nemm�ary In MO opinln 0 Me Mail lal No Pmt�far Maildrecar,and b ai W and mnd Or tend at wi an comab
dress Of such marnm crematory. vroalN ue aomgn.m.0m
FINAL 016PO aOB
TM person BNhariaed to random the v0mamd remains N Ma decnnd horn the orenalory by
Name, M.B. all Funerel Home
Aylnyo. 123 Main Stl ArpYI0 MY 12M Moor r 518433 18
T e amd remain¢ofdeclared will bediepmed ofaebllmy'.
nbraoy 6s person remaia ainw dye nNMe po98Maian Mmapemebl remellq
vmev cmm cmmaory
n> w , aauma�inem giy wen..io.a
the remain¢m M.g. KJmer Fuynl XcmO µ by delinry
in down or by mgpyretl mail. Ondon, Gom
OOS18�f(Pev. OVM) Pepe 2 of
Authorization for Cremation and Disposition
lldibs!N0 buowinq)
' 117 . 1) line Wool mats be remains are not rushed Whom coo days of wmation
Rre Vlew Crnmarory
nwac7.en may dbmm,of me rmairu In
an inetnevapg manner such as by aC nnp.
CREMATION
(�IONEolmalolowln9)
An um to by mail 05 a oral Mtlg command im Na When WrrinMd from
and hed wDID bHw
Iowa urd M and if IN dam is too mall m laid me anon aema remains an addldaMl told snblw may by used Jar tlmfmry.
C{a2 y.a _MUMb MyetpamM6a]. IMb uMeiakM Gpl ilno um la WrCMeed mamnvyB go'rvlsd
-"``JJJJ V;e Crr'.FY1 DAD Wall vamabd remain In
a seb bin W bry mnwn.roc dmlNary.
This AnmarbiWN Form wss pmvi and by interval A Gryrrm xge exacukl at
MB. plmer Furebl Her oAmxunt
1 n Main St Agyb. NY 12" wrtr�..w
am d signed by the fall Minor as whom.W on axeNtion xm usna
Ii have maims a mmplemd Wpy N this A MWmw tlm Form.
The
below
al the
rsomst in connotmoll of di$�Mon,who by
to the mou mmay and CWnpWWnl W Me InfomOlon manblrand In Y AUModaadon FomOadd aum s)me bmhded.
Irm.
SiOnad mislft layer July m30
shows CeCNa
2312 Counth Rd W 122J5 anday NY Gel
n wmaeme p�ye
WITNESS:
Slephanb A.Gilman
o.mr�me•�mnaw.
10163
Gra ory GeCob
Mwear
1>013-189i(Rev.W20) ppatIM3