O'Brien, Leonard Douglas Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745.4476
FUNERAL HOME: Eyd NQ P1
- f�_1T-� RETURN TIME:
DATE A TIME REMAINS ARRIVED AT CREMATORY: 7)I)( E)
NAME OF FUNERAL DIRECTOR OR REDRISTERED RESIDENT DELIVERING REMAINS:
—. diN n'9ER Mr(r
NAME: I(bJAIO IyS��
CASE R Syr
TYPE OF CONTAINER: 6*4 a (L , G fi
PLACE OF DEATH: I' (per 42r, c` 0 (y9?
ESTIMATED WEIGHT OF REMAINS A CONTAINER IR ( 1pp(`2i& -p
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION: _ Tal -�
TIME STARTED: t':"M TIME COMPLETED: IZ O(
PLACED IN RETORT: _ r�HYI MOVED: i lum Iz 16Ph
RETORT Y IN WHICH REMAINS WERE CREMATED: (G: Ohm
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN AS HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE THE CREMATION LOO SHALL BE RETAINED IN THE P PERMANENT FILE OF THE CREMATORY.
GKaNn:M a 511N
ST MTORK Division of °^�10 °��m g
STATEOf
DPPgtfDXltt Cemeteries in.W1,231COW N
iNeplimwww VK3Se
Authorization for Cremation and Disposition
TM1M AUWor w Farm must bcarnpmmE and NpnW prior W"N q or m"mRrcmnatlpn
CeR -w��l�i�OJi0 NwnW. � 4
Crrmamry Name: PINEN CREMATORIUM
M@¢es. OUAKER ROAD OULSNSIM RY, NY 12809 PtiyM. 518-7451
CREMATION IS AN IRNEYEMBM AND FINAL PROCESS.
Commit is c9med am by Flaung hie lemaim ad the bceasM are now C Memel blade Me mmmns Into a uemeticn Caner Wlere
to aresuWe Oimmnse WwdMme. Try bright dAAAMN llclMmm and ewmumsevery ingy Mbrim and 1,
xMm any all Mat MN Ea Iw after co mallon.
Follow rig cremation, the crematory wl[Nike reaaorehle ellons to remove ell of the mmam and oMx ma him Me �Imt'Wm
Natnbw, bA some mmmal and and maidee ad over bleft behind. The pe ?set"OMmillcdanW ell?deign m $1 hom
the remains and me saidemal and tmagn mamfial vnu by aiSpx.N M Be mgulmd W law. The Oememd Remove well Ed mw antl
pulv@mWInWameipie'esandplaned InWadeW"sMawM1 Cm 1M pa lw MpuNmdmduMl"
slllplefmgment la recognU bW am WINI11aaW.
OPENING OF THE CONTAINER
Me command may only own the mnWlwr MdNg the unoemamd human remains in hotel circwn WrKKS, nown as W OM "Me
identity of hie dewasW or A ensure mat no maWna is email Much might Injure emplayees or damage Me ertmmory pmpedy. M
human remains am dellverM in a Cwminn which is net suitable for cmmmllon such as uVmmanial or AIIMI mNE the
chernall wig require that Me rwAdmb moved Into a soUl container ba7am It accapb We nmmine. The meaning ate
comminerar Me bmakr or removal W model vnll Eve mnduccad belle a w eta and MII he done m [msry,will dignify and!reewmt
IDENTIFICATION OF DECEASED
Name of Oereeeed'. IEONARD OOuSi o'BRIEN Ma,pmyyamw MwMED
Lan Known Adaw: 11 EAST SHORE CR CHECTERTOSNI.NY 1=17
Plain of , if EAST ENOEIXt CHESTERTONN.NY hall
&A Elm OF Poe.81 Doa. 03/27/1939 oemwo 07110n020 EWmamd M19M 150
Des iw WCWW brow in whorl mmewwl Ee dtliveM.
FLORENCE CASKET COMPANY/CREMATION CONTAINER? CARBOARDIFIBERBOARD
rt DN
Saudi Or anted Ambassador OilONE ArIll Myc W
I smhYe aetlw(eegrms]eta IXtlwb WdmprWBd F19`✓ll An vniYm Instrument wAci wmmunt to Puthe
/ HWtlt law daemon 4=1
V ^^ n
LQI,iWM Fnwatlt m d eaMawnm WRuantto PWw' m I21 ore
will mmiutlr% ems; sAher mmabawove are NeTur a) wvlteOman Fuel Nmld lax
Seuon<ZU1 all Mtlw And W aetau creamaw of Me remassof the derevered MylburnWlp W Meews Is as
toll a.
LEONARD DOUGLAS OBRIEN
OOS18984(Rev Wzo) Page 1 of 3
Authorization for Cramatlon and Disposition
nn.nmrn ma uefodvxJ
Ni 3 Poamption SPoUSEM1NFE
1. A pension Mrsgnsetl In irmng Wnlanl W Public HNM Live 3etion 41
i The aurvlving apw
L. Tne wrvrving tlomani Not
i. My showing clula ¢igrae¢n yews M age or When,
4. Awrvving parent
S A eumvmg Sbling elgueen years of age or Near,
6 Alawfully aporm tlfootlman
1. Ary,pwwn(e)eighteen years of age a,other¢Mtbl to snare in NO ewah and wMianny nsr in Aa0ars51p to the deS9wE',
S. A dulyaPooi nlM firiciary of the states
0. A chae M¢M Or rele4ve istw has execNea a strain droment Wrauam W Pldk Healtl11n 5tttIm 4201(7);
10. A cniN fired officer M a county or a publin etlminisM1eb aFgpndJ Wreuent to the Sulttyal¢'a Court Pramdure Ad;
1M. Any other person'Mlo le acting on north of the oeceawo cop wM haseeeMeN a widen andemeM pu9ueM to Pui HmIth
tear Mercer 4401(7)
ALL 1HREE 0 Me fWwvty
v Y)� NNa tereby aPom.Mane Andy Of Me dNaAdstltices net OMdin a Not INpwy Pod. INVISr all, ra4'W lveimplant
w ralioxnveoeviw aN Met arty auU matenalsxere remauM pnx lotMo-mtion of Mb AufMrlmtlan Foam. FtlIUMW mov0
J1�(/w/a��Ib�ma prlorao Wremation cosy reelJaln funn mlMcwrlumry anC crarrlvrwy pnwnrel.
j�Wd¢dkmthat lnaoaWSh�[ g"nb JPMESP. MrDERMCTT
pmawy✓^'aw
regerEln9 Na nnlovelMeM FePINE NEAI C REMATIX UM
Montreal wahee to Presents! dvdlue WiT xry Faama4iarg lMN4wwryhn'ily mem[erdNe
' i not reaponsiae tartly asi of porund fume"doorCMaiM Drat tMremaina NNa eaW d. POlsoMllmma leh In
/Contionfor Or vi NO sadden sift baGwhgeO by Prof aBon proww�ra cannot W re4NVN assay owounin.
� Ov�3 NW Mmby and PINENEWCREMATCHIUY
xw bCfOmam tlfe femtlm of Oaf WO.
f rawl(oonCe AU
Mare,NAby anMmlw the renNE funml 0lraclw W goaMa for WIHery On and cmnNon by an aXwNM
rarnafary,N Beemad Mceaeary in Na op roan of Me Ni directed,aryl W anend WYfomr W prov1060e comet name and
adtlreva M such atNmeM1 cematery.
FIWaL DISPoSMON
no perYln aufficontred to reserve ads cremate]raTtim of No fb%aaed hmrtlR amOWy'O.
Nome, JAMES P. McDERMOTT M EMPLOYEE
Address, 9 PINE ST.CHESTERTOWf1,NY IV17 Phone 5l&4t4n!5li
lna oamMN ranam of(W aetl'eYll M CYpMOd N Y ICY.W:
n 1w am reason M.pMaan named d,N.ao.M min pmwmlm d w aende a mwm.
PINENEW CIUMIATOWUM is eutlxaintl W ylwpaueetion of
WysrvW
Ue ranelnab FUXERPIHOME.INC. bydMNary
in careen artym NhNl coot. w�wsLErJNARD EELIELAS9BWEN
005.1fl fIRev. 0AR0) a Pori
Authorization for Cremation and Disposition
1-al(rJna ran.M¢1
1'J WN understand Had If the remains are not dam xMin TW days W orientation,
PINE VIEW CREMATORIUM rrMyaeygaNMeraritlnan
aniaymernsai manner, sucri as by scallion ng. Punucw
CREMATION COMAINERNRN
IbEAT ONE d 0wo Wowmpl
An um to by uses ae a contana(w Ta!daisies rmans has dean gaW9B]IKm
sees de,w ae as Where,
IMb uMaLand Tat IF they um islro emal b Wd V9 XNR aemaed!remains an a]titidW ngel container may be used MCMMry.
✓ 01� amMw MP aMwd lwauwerMWn ItMm MMnwemadrMPMaecmrded
PINE VIEN CREMATORIUM will Nece are cremated ramains in
rw..ao..or.A
a ngie Emiwaary ;o lairer be sensors
This AUNwrseIM Form W IraisM Ey JAMES P. LMDERMOTT was showed at
BARTONM DERMOTI FUNEFPL HOME INC. n..sowvv�ary
c..vx.m
B PINE ST CHESTERTOYM,NY 12817
and M signs] Sy the funeral diiZlp as withess to he exeareon
WJe naw rear J e darer" Wpy a rely AUNorlratlon Farm.
The parsonlsl ldaydi Ways ielan Te peROn1911n wnNa of dMpoation.who 4 Mgnang MU AUMMnIM Foml,a s)
W Had accuracy and awnpMenxa a tlas Inbntutlon coaW In MY AVUmrtr Form and 8Ww 5)Mie blepoNg
Signed NM AM days JULY
ELLENo'BRIEN Q 1
PC BOX 720
CHESTERTOYM.MY 12017
rorao.nmmwn M+
WITNESS:
JAMES P. McOERMOTT
123W rrwvnnccrvMr
D DOUCU30'BRIEN
ooalam(Pary StrM P&I