Johnston, Shirley Marie Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: (Rpe 1pJ RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: 7I14I10 Q"q�j
NAME OF FUNERAL DIRECTOR OR RECRISTEREO RESIDENT DELIVERING REMAINS: -
ANA0
NAME: 5H[p/ A .'1//1Ywo CASE D QJa
TYPE OF CONTAINER: i kq;Ae- p, ,.A � 1
l y
PLACE OF DEATH: ZN &%L 6otf. (r I1 1
ESTIMATED WEIGHT OF REMAINS & CONTAINER_ /00 LFT
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION:
TIME STARTED: I6D6Aa TIME COMPLETED:
PLACED IN RETORT: IRIS AM MOVED: IIA F11 IT'YOOM//%OR'1
RETORT# IN WHICH REMAINS WERE CREMATED: GELyL Qp(/O I1 ' ICI
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SNAIL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
Fee York Nate
Department a(5gte
NEWYORK pIVIS10R Of DIVISION OF CEMETERIES
OPPOP1°"'" Cemeteries i
01
Taken... ni
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Authorization for Cremation and Disposition
This Automation Form must W completed and sign" prier to Napery 0 remains for restated.
Data. July 13 20ZO Number OP
Crematory Name: Pine Yew CremeWiVm
Address;: Quaker Fluid Quekinsbury NY 128N Phcoe'. (518)74544TT
DURATION 18 AN IRREVERSIBLE AND FINAL PROCESS.
Cremation in mMed out oy placing Me remains of Me demanded ant the combiner holding the remains into a exceeded chamber whom
May are subject tc Intense heat and dame.The Ixat and name will mmnwb and consume w Whing eaupt Mna and make,
which am all Mat will be left Pear Cremation.
Fdlavimg aemation, Mecrematory Mil take reasonable woo to remaN all MMe remains am at"rmM dal from the uematian
chamber.but same minimal dust and residue all likely baled gamed.The crematory will ee to incidental and brei9n makenal had
the rename and the incidental ant aregn maternal Mn be gathered of as required by kw. The mu mand remains will be mecMnicalry
law vimmenta Ismail came and waceg into a designi wnmlal or I.M.Cnmmd remalm Densraily ere pulverized until Me
single fragment Is recognizable as skeletal tissue.
OPENING OF THE CONTAINER
The crematory airy only boon the container holding the ur o-emaad human handles M limited caWmsknms, sUU.er b WMrm Me
Itlenday ofthe de erased orto ensure that no material Is endorsed which mom Inryre employees or damage the vennel p ck okay.H
human remains ere delivered Ina ca inerwhlch is her sulublaror cnmatlon such as ceremonial or rank Casket Me
rematw willre uim Mat MeremainsWmo InWasultaksconklMrbseom Itaccapk Meremalm.Theopeningda
wreaker or the transfer or removal of emains we be Conducted before a war ess and MII be done in privacy, with dickey and respect.
IDENTIFICATION OF DECEASED
Nameof0emuad Shirley Marks Johnston MaritalSawc Mam
Last KnounMdrom 4 West Main Staked, Cambridge NY 12815
Peamof°edlh. Seneal Hospktal, 211 Church Street. Saratoga Springs NY (L'U. 1
Sex:0M0F Age: 98 DOB: 0412511924 DamdDeaM. 0711019090 Estimated Weight I00I4
Descnpikon of makedmentinth In which remains will be deliveretl.
PENSION IN CONTROL OF DISPOSITION
(Pomm(s)N ccntrclddleoosl✓en, refcal ONE crime blkwingf
1 arbil are the desianaatlammof Me bememtl maltreat in atoll cowmen hla✓ument executed pureak WPublic
Health Late Section 4201,
40R
MMe have no knowledge Bad Me crowded executed awnMn instrument pumaki W Public Health Law Section 4201 or
anki In a ecnom forge dkposkbon of his or her remains and like are M demands)pat s)having prbnH under Pabdc Health law
Skit 4201 and have Me right o emhonR cremated 0the remains of the decried.11I mlatlonamp W the deceased IS as
Idldws'.
Shim" Marie Johnston
armwearraW
DOS1 III(Rev. W15) Page t a
Authorization for Cremation and Disposition
forest from Its list WMwl
Number 3 Dmrritgm. Cl a.uiiVl L.
1. Apemen designated In writing Wrsuam to Public Heats Law that 8201(8):
2. me survmng spwn:
:a. The summing domestic panmr.
a Any summing cMld eighteen "am of age Or olden
l A surviving parent.
S. Asumming sibling eighteen yearn M age or
9. A lawfully appointed guardian
1. Any Town list eighteen"am of age Or olderenRlkN to sham In Pe estate and wM1d Ware wheat In mmFmsli to Pe dxeaeedl
B. Aduly assented fiduclary of the semis:
8. A dew friend or remove who has executed a wntbnstatement Pursuant m Public Health law Section 4201(n.
10. A shim oral officer of a county or a public administrator appointed puromm to the SunOgele'a Court Pmwdure Atli
18e. Arty other pawn who is acting on behalf Of the decomed and wfio has awarded a warm statement Wrsuam to Public fission
law Section 4301a)
( TNFEEMIfm =Wwl
IAVe hereby amnm that the body oft"dema¢ed does not contain a batlary, battery Two power cell, mdmatlive implant,
onadieatlive denw and that any such materials were removed pnorto the execution Of IhIe AOMOdartmn Fil Repair m remove
lM/f Items pi cmmllon may result In ham he the cnmamry and cad atM graenrol.
UIWe aMm thatireWglons have when given to DONEENS hdlA
regarding the removal of any permnal propery Or wher thing of value when any person m in8 balm or any family memMr NNe
Monarch wishes to museum Pine View Cremaorium
is not responsible for the removal M personal items from Sg container or hem Pe remains of Me danamd.Psnoml Ibme Its In the
opYltion or with Me rem sham we I be destroyed"a cmnaflon promises and cannot b m Wd after mmatlen.
UrWa Mosby authorize Pine View Crearramnu m m
mce aw Me smairn of the Oeuod.
FINAL DISPOSITION
aT Pul�(rwnw M1me mremiva NeaematMmmaindt"demardho lheaein b'
Name if t- y4�.x I1 cN' it �I�rn„ I;6-k
Address /e � Im A44\� S1 / mrofntN. �a.1/.If IlU�phrye: S/P ' 7g1 - LL24I
The CRmaled remains W chrommed vAl be disposed of w fellows. VC
If arty seem Me parson named above does not lake tradesmen W the cremated remains,
Pine View Crematorium leaulnrvimdmglvepas»aNmol
the Anyone to Champion F bydmlvory
wssx.es
in down or by registereail.
d m
ShiNMart J01mithn
.,.a e�
DDS 1dm-f(part, OWI el Page 2 Of 3
Authorization for Cremation and Disposition
hithe MMWng)
69=11iVe uncesane that if me remains are not claimed not 120 days immunity.
Pine Vb Cm MOdum may dispose plate remains In
onmemevame manner. sui as by smnmrmg. " r
CREMATION CONTAINEflNRH
An urn to be used as a mMBiner for this mrrubd remains has been pu Wsed from
and atleauibed es holows'.
IMa understand that tl the um is tw smell N bold the army puma b d remain,an aMMonal rigid mMelner may 4e used for delivery.
_CV7
[p -
V454� AnummmlympurcM9ed. INJeuMmWa MetRnoumispurtlwedoraMervnse provided
Pine view Crematorium will platy Me cremaed remains In
a ngid temporary container for deivery.
This AUMonzatlon Form lines provided by DONEENS NIMS was evemted at
Oareton Funeral Home, Inc,
E9 Main all P. O. god RT Hudson Falls NY 12839
and as signed by the funeral director as wMess to Its execution
I/rre haw rewrved a completed copy of this AUNotlrarlon Form.
The peman(q Identified borax Islam the PwasMe( In control of dlepwibon,who by signing that AUMwfeatlon Form,atusdM
to the accuracy and complNenesa of Ma information contained on this AUMwlnOon Form and auNanm(a(the forsooing,
rW NN 13 dayof July 20 20 1)
br� rt I-�u V.lOrna
Twy,vFyvwmvw Away.
show
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SMrley Mane Johnston
ory
COS-10904(per,Whig Page 3 or 3