Denton, Clara M. Pine View Cemetery & Crematorium
Quaker Road
Queensburyl NY 12804
(518) 745-4477 or (518) 745-4478
FUNERAL HOME: AEEGJYkO RETURN TIME:
DATE 8 TIME REMAINS ARRIVED AT CREMATORY: -I/S ) TS /Out
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
CAEE PAffALba'�
NAME: C A CASE R
TYPE OF CONTAINER: IT( /1 PLACE OF DEATH: 30 7r O lit f4 I,y„gh �_ jn1
-�
ESTIMATED WEIGHT OF REMAINS 8 CONTAINER yb At l:jG
PLACED IN HOLD:
PLACED IN REFRIGERATION: MIT An
DATE OF CREMATION: -7t/- UzIB
TIME STARTED: I4k TIME COMPLETED:
PLACED IN RETORT: l _MOVED: 2
3-0
RETORT A IN WHICH REMAINS WERE CREMATED:
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE:THE CREMATION LOG SMALL RE RETAINED IN THE PERMANENT FILE OF THE CREMATORT.
DePerlma yiii al
NEWYORK I Division of DMMO OF IES
on,C �1111I f
STATEOf w Comnmre A ,nw
° Cemeteries VDCm
�,M1e1m4a22$
Authorization for Cremation and Disposition
This ANbdlaatian Form must be comin W and signed prior W eewery d remains bar cr Con.
Owe. 071OW2020 Number.
crememry Name. pine Yew CMMat
Andress: 21 Quaker Rd QUeeni NY 12804 Pnone: S 7K
gig;
ovlTaui Tsmen ecrea.llcnle reoeu1�roimr1¢M1madet o bvreryyM m lwa awiClilnD.wsnT aapM1uMaamr attoelee leM1 mIvenaarcMrymitlentMynrte1nn8m9a1:el[(niwnmtlso in lwo pMrieltl eibbg enac nermemmee acherl4Mireoiarmnml
OPENING OF THE
uIsebllmyI
CmnaW nnnlna pananll Nn'¢sd uMl no
CONTAINER
The crematory may max cMn the consumer hiding Me ur-cremated human remains In limited ciwmances n , even as to confirm Me
merely of seate sec or ensure that no rectangle endW N which might injure employees or damage the cremetdy pmpem
human remtlw are cautioned mammal net whim Is not suitable mr artmation such as CnemonWi or mr lmb me
NTnery will mall that me remain$ be moved Thad v suitable count nor worth it accepts the MmviM. The Owning of a
codamer or the transfer V part of rematos snit w mneucced before a witness and will w time in wl wth miles and rw1aM.
71011 OF DECEASED
Name of 0ewased. Clara M. NentW MedkI SMWs' VJIEOWBd
Last Known AdErwe: 30 Tripp Lake Road, GrMdN rtavn, NY 12817
new of Deem. Deceased's Residenm, 3o Tripp Lake Rated, Clrea seven, NY 12817
Sex'. OM INF she 88 DDe: =511931 Dale of Deem 07I08/2020 Esdmaw wdgm. 80
sMw Mmm 0 caskeUwrdaiwr N whim remains all w relented.
New ENIantl Cremation deluxe container
Psiggisal IN Wall 00F MPOSTON
(Fwwi In coma Ndisposal mdral ONE of me wownp)
1 amM1Ve are me despreteti apers athe devout dealsnned in a will or amen instrument executed Wrsvant to Public
Has" Law Sedbn 4201.
-OR
INIe wve no moneshe met the crossed emmb] a written mathimenl wr l to Pudic HesIM Lew Search 4201 or
wiN wmaimig photons for the espositio^of his or her remains and IMe are me Porsa^(e)having monp under Public Health Law
Section 4201 and wveme right to Museum cremation of me remains oft"ettea9ed. Mylour elation rep bore dxea ed ie n
balbxs: Clare N. De160n
Pagel
DOS-1896 f Fish. 04n?01
Authorization for Cremation and Disposition
!Im[ert frmm On Irsl below)
Number 3 pmalptipn.Surviving Child
1. A person desgMM In writing pursuant to Pudic Xeallh Law5xtlpn ROtiJ):
2. The surevir9 apwee,
2a. The sharing eomeaen pagan
3. My pumps Miw engineer years of age or cider
a. A surviving parent
s. A surviving sibnn9 eighteen when of age or olds[
d. Alawmgy appointed Mountain;
T. Any days lb)eighteen years of age or alder emitted to share in estate and who sare arced In persoonnel to ordered.
a. Aduly appciMl tldudary M the estate:
9. A cline Rend or rakMe who has executor a vended abtemart Wrsuant to Public Heats Lax Section 0201(7).
10, A chief fiscal officer of a county Or e donih administrator apparent! pursuant W Re Sunopale'z Could Promdure Ml
Its. My Other person who a acting On behalf of Me deceased and who has adsorbed a armed Statement pursuant to Public Health
Law iealan 4201
pow ALL THREE of me mutua )
q� a. IhNe Mneby afirm Ilutthe dory Mthe dexyaed does rid Pontain a bettery. 0adhry puck, powenrell, rommay live Implant,
or radlnaclave doves and that any such materials were removed prier W the execution Of the AbMorhAon Form. Failure by remove
these hems prior W cremWon may result in harm to the momentum and amatory "monml.
INJe alum that InstmNons have been given To David Alexander
re aging day removal of any mretul pmpeny or Other Ming of value which any person signing dense or any family member of Me
dersamd washes m preserve. Pine View Crematory
Ie non neerynelde Wn Re mmovhl OlpeMPol2ems form Me COmainer0�(rem m.Rmelns ortn.aecaaeed Pomonale l int
cartel Wealth Me mmalm will be dentro system consortiumpwass and cannot the standastandastandard! m after creation.
4 Ilwa hereby authurre Pine View Crematory
��' Waremate the remalm orrem eac...ed.
(ImMOOPTIONAL)
Yin hereby aWharma the named funeral director W provide for dNlvery,to and crematlan by an afterman
remmom, hdaemon necessary in the abandon of Me funeral director,and to amend this form to provide the correct name and
address of such astern ecrematory.
FINAL DISPOSITION
The person u0mized to RWive Me vemaletl remains 0Me dtteased from Me RemalOry IS:
Name:Alexander-Baker Funeral Home, David Alexander
Addrms, 3809 Main Well Warrensburg, NY 12885 phone; (518) 623-200
The aadan d remain Nmuseum will be disposed of as follows:
Return to family
If for any vapor Me pemon named above does not lake pmsml or the cremated remains,
Pine View Crematory b shorthand W give possession W
G
they remains To Alexander-Baker Funeral Home by delNery
ovwW wyHw
in pawn Or by registered mat. Clare M. Donlon
DOS-109e-f(Rev. W12)) oa+ Pape 2 of3
Authorization for Cremation and DlspoSition
fleGal Me Wxaa„e)
�_IMIs undenbnd the it Me remains are not cause within 120 days W cremation.
Pine Vrew Crematory may mwme of me memoirs in
an iimrievaele marnar, eunh as by sr.fterre �
CREMATION COMNNENURN
(bbigg ONE of the fnwm,vrg) Alexander-Baker Funding
M um to he used as a oCotainer for Pe cremerM remains me been purchand from
and is disordered as folowe
INJe understand Math Me um b too small to red Me enure Cron romelra, an addhimed rigid mMelner mry M sand by Wiu .
— ,F--M um Is net yet purtlwed. Were wNwaland mat it nor um Is Pur aced or oMerribe proves
Pine Vrew Crematory vtn phew Me aemared ranges in
we..no..en
a might embassy,wnt for deliver.
Theannwb ydn Famve proi M• David Alexander "a executed at
AlexarMer-Baker Funeral Home
UN Main Sge, WanansEurg, NV 121N5
and a signed by Me funeral dingW as EMI W Its execueon���
IMIe have nermeed a Completed copy of the AUModze WFomrThe .
s ADM�8Wn
he tM accuraacy and mpltlenms0 Me Informtion contained in Mis AulWzarfm Forms and F subnormal thero Di"igsNs)
legnedid s Rth dayar July ��p�2"0�
KermethJ Damon
30A40 Trip
T 'pp I.Rter Road, Chestertown NV 12817
WITNESS:
David Alexander
6u.vausrvm.mrer.,.r aa...
f 003d
Clare M. Denton
V ve.,es.o
DOS-III(Rev. 04120) pageSMa