Hemsworth, Leydon J. Pine View Cemetery & Crematorium
Quaker Road
Queensburyl NV 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: Ip p fTOJ RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY:
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS: -
PaLpMD NAME: �EYII ISI CASE D 1
�
TYPE OF CONTAINER: I.RIMT.p (,b/ IEEE„ lift
PLACE OF DEATH: GZ ODMELa_ W sR uoyRda sPo w
ESTIMATED WEIGHT OF REMAINS & CONTAINER /Do u
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION: _ ?MA /70
TIME STARTED: MAD An TIME COMPLETED:
E
PLACED IN RETORT: I•ID AM MOVED: X/f ftnI [am
RETORT N IN WHICH REMAINS WERE CREMATED; f a �V
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.
. N<wY<,arare
pw.maam Msub
N iYORK I Division of
DlvMloo CEMETERItl
n<cemwe gue Area
OPPM°"'^ Cemeteries m
TeNwme.Isla1P165xrza
Authorization for Cremation and Disposition
Ttlb ANMWn Fans murtM comphbtl and slanw prlorb d,g mof remains far emmvtlon.
07101 2tl Number
Data. Si4
PIM VI :uMMa ly
cmmmory Name (are) 745477
210MXer Road.Oratorical NY %RN)4 Phone:
opw
IS AN IRREV lBLS AND FINAL PROCESS.
ce ad bNMMrme ,
cafia] create/ gdclnB The ndrmnalnolme�Maded and Md cmbiNl nddlnaman, iliaca
acb]Wimande Mancarfl ate 1Te Ilutantl Soma MIl InclMreb and wnsumn averyminp eaapt bore and meW,
small left alb,anmetlon.
a some ma Wdo will Mite reewruEbefloMaremove all o1Ne remains aM oPermabnelImm Na cremd4on
No left island
aM Me nudenblew bre pnmmeknal vnfte will 'IbeureoulRd Ylaw. Theruented remains wlllM meClan1 ly
rivato Tall Nc 3lam an skele a tluwg"d wnulnMm um. Cmmabd nmalM Banerally am puMd,M un41 no
As
THE CONTMNER
T,z eeemabry mry only epdn IM1e wnulnel M1oki�g Nd unuamebtl Rumen remains In limited or daageMe inner wnfiml
Xbn41yo11MdeM u¢ mOendureM1 nomabnal'Kendo w iMMi the
inlureemployees or damage Ills uemalory prepeM IF
emhumanryll requirelSat Wlna remalre bar�N Minot subble fee CMM160n such lnto a sulbhM consigner wrore ll accepts Me mma ceremonial olns.nThe codinal g ole
wmemel of Me bareM w feral Of remam All M¢ntluc@tl M(oR a wilreu and wall re,arms In prawasi war did nary and respect
logeriftricall OFD COED blamed
LryEan J. HemmM Mai Buul,
Name of DereA¢ed'.
real NMwo Amre¢.:
4z pm egal Wry,sAreMga spnree. xr UNIDO
Place of Death
az Donegal Way. 3areloY Spdree, NT 12 � /1/'�
77 10/2211942 Dmafo o7roarzox Faemmd N+aeM�
3m. OM [IF Me._ DOB'.
ce¢uiphan Or amXeVcunlairer'0 vRntll remains Ad LedNbwN.
Cardboard Box wMlooden Base
VIROIL OF oN
(FbremisJ bl am4N orawunbm.JYN ONE orMe kLwinel
IamMHan Me designated Aram of the deMasa]de¢pml M a will or each instrument pubuanl So Public
HeYm laws n4201.
0
IN prusemXnowleoge Nal of derea¢Memwl and
Ped am Mee oul rys)her PWlla H underBeIer Laws Ifte La ore
µillgan14Wi lid hm the
authonof he asorea remains andIMare Meperscn(s)MnrppnoMYtelp W Pudo nOLew
Slogan pzpt eM IlevemB drMb aulM1ove cremation o1Ma remaanaofma Mttmad MYIDurnlaYoreblpto tlNdeUuad Is Y
foliose Leydon J. Hemswanh
Prater 1 of 3
DOSJill(Rev MAST)
uthorirztion for Cremation and Disposition
¢aryom a,.nstoemwl Dlaw Nemswwm
Pm, P Daeenp5m:
1 Apmwn eaa.n ,nwr gpursuantro Public NeaMlan'Seaonaz01(3)
1, TheravenistraMe
b. TM survlsirg tl-meegh ginner, apem mar3. Arry arrow,
OWW 0. AsurviOng parent
5. A surnving siblinge minarn Man of age or door
S. Ala liy WPOladdgoaalon; deer enWN Mebare In as esbk and who leare they MNicesMp role aeWasM;
T. MYpenon(61 egMwn Manaaym MroPubHC Hedlh Hiatersemna]01p)I
11. A duly appoined Mutlary of Me estaM,
5. Adrm"M or helm who has epmulatlewntlen sbmmeM WnwCourt
10. A Her men YMwr a a olunly or a public admlnrstlim WpuiMatl Wrswnllo Ma within Salmon PrIXmJYn
t0a. an Steer romi why
m wring on Wharf of We deraaaed and Are has mecMdawhXen sbkmentpunuaMlo Pu Aidbllc NealM
tin THREE a MY Wassary)
i�VM 1µp 55reM 0.MMe,Mebodyof We tlereasetl dc9s nMwnfainabefbrv.batlery Pant, pPaer all, ra0�¢in6lmpleM,
lrina-I[a18Miva daN2 aM Mel any such mMenaLe wan remhwtl prKK W Why shim yof oin ArMoyhossml Form. Poflun b rernow
� q��a/�/�/a/y0 to rnmadon may result in ham,WMG cwdMMmf and memafmV bMGeHOp
sy t(,{ IM 0,My Man moretime hm[Mn9�n W pew wMr
VlNoWsmNin—g-ihe removal a arty symorml PrcgM or Other Ming Of value whist,arty passion eghr;b&ow marry hardly ma aNC
home View cmnarom
steadied w anany W Pmaarve. Nrr^^h^'rc
m
me
8 nor estimation for the removal a Wrwna111eme hire be,mYamer or ham to amsaMsdecaesaJ. PanNalMmsl n
wM bm remains sell W dit"W b/M mNmrocee
s m ,proceed and canna be hadviaa aver Cmnauon
%rw Ncw Lremaory
WNVaherebY aYMoam
W nremam M.remalrreaMa eeua.a.
Qrveef DPTIDNAQ
base herelry authorleaae named huni deer W pro it a MdsliverY Wand Oamarbon by an almmam
. rea yIfde xXemnp bcm:lay a WlnWn a Me mnenl alrxroe aaa ro am.na Na fom ro pWvlaeue mrract mme.M
D n e9 MwRR to rewNa Me aemaad remains of Me densest hom Ma Mimi b
me '.
p w
caepemior runaral cam
Name: (518)bai
Address 402 OMAN Ave Saratoga Springer NY 130Eo PrpN.
The uaeeWdremsMa see wfHbe diwoeab Olas W11 yr
X be any ream the Mann vaned shows does nor are Py aMe `pmnatM mmtlns'
she View Crematory msuthcazed Wye posseuWna
�onw,er LmpwbWe Parent Cen,lro bymbeent
ire Nomura i —... I I
in Mason On ny habaWreE mail. Laldon J. He,rmxwM warm
ppi
ooslarti(Few. "Mo1
Authorization for Cremation and Disposition
nwpwmm
IM@ urvJsntaM Mai ilbe remains are nosdalmeE wlUb 130Eays MnemNan,
Piney Cremabry
n maygspwe of MB Rmalns in
an irteVlewNe manner, Such UEy¢reimrin0.
Icd�CREMATION COWAINIUn
ONE dMe bpuwiny
M um M ass,u as a wnbirerM to oerri rain ras been WNasMM1vn
aMUEesall4l' asuM
Wry uMsrthM ban IFMe um IS W Small SO had Was warm aamsed rains, an Seasonal Isi d mm ary may to used for delivery
M um ¢nal}gl puMmE. N^H unMnbMMtl ilno um la punM1awd w oMemeB pmvged
Piney Cn1ny
a»w mu paw the cremated remains In
.dga tampw.ry mm.iriw tar dNlwry.
TIie AUMONxstlon FOlm cop pmmd 1py Holland G. Hoag was sKNb] at
Cwn[38sionak Funwal Care, lm
403 Mi Awe. Sanioga Spnya NY Ii
anal IS OignM by the SeveralElrec n r as wiiress Is has Semi�awmu
Ii Aa a rewivW a mnPlaled wpy of this Augorhatlm Form.
Theo parmi IdeMMd below,blare Me penonea)In cinhW of deposition,Mro by algnlag this Autl ostund n Form,aWsgsl
b tlnaccuracyay and comPlemss of Me lnbnntlgr contained We Visa A,decraftiblonF d• sl MebregOlpp.
slam,Mn BM any or Jury 20 ( � �
Days,Nem¢wwM
42 Doi way. Swekga Spin p W 1$
mrNESS:
Fro O. lkeg
11534 gfaniasrriw ai+rruwfecm
4W'n J. NemawnA
DOS SW(HSV. D&I PpB 30fJ