Gorham, Vaughn Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745.4476
FUNERAL HOME: / rA!1 OWE_ RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: _ -IINIM IF.�Ah
NAME OF FUNERAL DIRECTOR OR REGRISTEREO RESIDENT DELIVERING REMAINS: -
F /4AW Kl*
NAME: AURP 50CRAh CASE QZ2
TYPE OF CONTAINER: p A'Aft V � 1 A4- Yw4 yI
PLACE OF DEATH: y, R'yik, LF RaL IY Cd-:'/
ESTIMATED WEIGHT OF REMAINS & CONTAINEJR L{O PJI
PLACED IN HOLD: Mn
PLACED IN REFRIGERATION: /I-� n„
DATE OF CREMATION: 1)I4 I IO q
TIME STARTED: I-TP PII TIME COMPLETED: LrY"PPJ
PLACED IN RETORT: I�MOVED: Z:?RrlI
RETORT N IN WHICH REMAINS WERE CREMATED: SWL4 QI" Ny
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE:THE CREMATION LOG $HALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
n6me
O.Peran tesua
KSTIT BWYORK Division of DIVMIOaNNreOF CEMETEMES
°'PORT""'TM Cemeteries D amewr ,gym
Tewp6me.l6tel+/+63M
Authorization for Cremation and Disposition
TINT AuMMea"on Form must b complMed and signed prim W delivery OI Mntlns ter emw wyn.
Oeb: 0711MO20 Number. BZZ
Crematory Name: Few chase Crtmffiry
Addax; 21 Quaker Road, O"e q, NY 12504 pl (5lin 7drWT1
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation Is 4n ONEy,p4ay tM remains OII dean am thoxnuiner Mdmpdw ranaim more mainstream tlIY N
bey we subjected In intense heat and flame. The hest and mama will lndnerN and consume evsryl OXpM eons and will
which are all mat will b"11 alter cremaYon.
Following uematiin the crematory F ll ltla reason of a debts to remora all Mhe romans am Omer mffidal from the memahn
chamber, bid some minimy dust am residue will I&Ny be Nft Whim The monetary All separate,IncdeMal and Resign neweed man
Me rameiw and 00 modenlal and foreign melenal Ad be cement required by law. The mamatedrehere will pa maGanicelly
pulverized into smal pie as and placed Into a designate consumer or um. CrsmeW Mnales gwwnlly are puNnuad urMI no
single fragment is recognisable as skelaeal Wsua.
OPENI NO OF THE CONTAINER
The MnsatOry may Only Oman Me cont&rer hONirg the uncremated human remains in limited anxime ngs, such as to mnfitm the
idenply of and Waesed Or to amuretM re maucaisenclOsed which might ileum employees or damage the memory promdy, H
human remains an deivered In a conalner whit IN Is not su IN tom fm crs "m such As"r Onlal or rental cash(me
crematory will require mat me remains b moved Into a vuiuma mMtln it Were Nacpem the remains. TINY slowing of
commoner Or me Iranshr Or removal of remains MII be conducted bebre a Owes am MII be done in ervacy will dgniey am rasceel
IDENTIFICATION OF DECEASED
Name M Denewd. theater Gorham Mental Sti Dlwrmd
la&NmwnP mss: M Fellgm Rmd, Smtla NY 12302
Play Of peM: bePbet H"O Nu91rq 6RtlladlMeLwl Center
Se.: OM El Age. 77 D0a 03/20/1939 wumoeah..0]/11/2020 Enmatad VMig 166
oexnpdon of crawww tairerIn which remain ben bebelinred.
Cardboard Box wNJooden Bane
PERSON IN CONTROL OF MSPOSITMN
lPa2mlalmCCniMNdeNaM1m, mina DNEMmeh W
I amMkae the dersianaed acemoftladecal designated in a vnn aw roar menterecuted pum mI"i
HeeM Low Section 4201.
OR-
INJ1 haw no knoMedge Mat Me emotional exxuktl a when n instrument pu relent b Public Hill Lew SMionAM t Ore
mntainirq oiANO,a Mtl4 dHpos en OI his or Ner anamr;and lM are Me towns)having priority under Public death Lax
Ona201 and hew Ma rgM to au a mammon of the remains Of the deceamd. Whour Madomhip to Me dari lsv
logdw%
Vaughn Gorham
DOS-Ie%f(FUNNY. W20) Pagel of
Authorization for Cremation and Disposition
town pan tin gdp )
Nummr. 2 oeemptbn: vvonre 9rennan lGauenre0
1. Amo,itrugamel in will pusuart to Public HUM Law 6ardon Qll(]j,
2. Msurvwing secure:
U. now surviving dorerec parwor:
x My surviving mild eighteen We*of am o'amr'.
l Asurvil parent
5. Awrviny shop agreed years OF Who or Wes.
G. A Randy appoimed Moment',
). My pane lal egho n soots of age or older en msham N he assets who who Were ticust in mationehip b lM de Bar
F. A duly ymoimm nencery of Me eatim:
S. A does Fund or mbOve who mare eMumd a mn rmmment pu*uem to PUNic Heats Lax Ife OM 4201mi
10. A chief nswl officer of a comil apanic admmmtra appeared moved m me suoogam a court Pm um AK
toe. My offer Po*on who m mang on behalf of Pe deg am me has exe a woman statement pursuant to Public dealt
tWay;5eMon 4201p1.
(InttlmT ALL ThREE W Me brodand
IANa hereby affirm Net the army of to da awd died net"Win c M" Gatmry pack, cower call.*dicacMeimplem,
Joel it$,"am Pat any such mffiwis m9moard pn.r' to MB mrew40n MMmAMwleatbn Form. Fellummmmws
Msef Items prow m cmmatlon may hall In harm as Me cm=Wm and channel nnel.
1=9 affirm MetimWNans have men given b Rolland G. Hoeg
ivwwerui
ding Me wall o1 any pe*Oml popery orteam Ming of vMe who any carwn mal mm or any M1mily murder of le
mwawd washed to preserve. Plru Nm:Cmmamry
is net*apsniltle Mr Me romonl of harscnlHmmS Who the combiner or from Me remains of Me dewee d! Pm nal Items who In Me
container or with Me homes ne will me destroyed M Me emmatwn process uN cannot ha mxaw r td aMr c AHoh'�12d Me hardly suModae
PIm�C*mabry
4L he emmate M ,mmaim of tlm droned.
ImfW OPn0NAy
Me, auMorme the named Nn.nl dlreMn to provide for delivery W and emmtlon by an anemNe
mnawrv.If dwmcd neeasaa ry In Me opinion M the b neral dirMor,and te amend Mm roan le pmvsa Me amend name and
aom$s of such almmam ehomabry.
FWALM MSITION
the pmsan Whomeral to reteiva We demand remaln90f Me Ms hom War =q b;
Nmm ComWaeanam Funeral Cam
Mdtwe. IO2 Maple An., Wool Mi W 12M pdetin (618)Md.dBM
lM cremated mmYm dd aS vall be d6ecau1 Of m bllom:
,AwtN Tv Z y
rcM any*uesn Me Ml nand aFhB data rat dw pOeeNsbm dMe adnaW mmene.
Pim Vlewcmmdory aauMasud b pre pros lonof
Me*mans U, C pmonam FumN Cam lea terminal
cones or dwpmsd malt rya lw VN nOcMan
D06-l6 (Rev. WOO) vaAw Ppe 2 of
Authoriution for Cremation and Disposition
(f ime Tuaa*+gf
INJe understand mm It Me rzmama are not aalmb wBM1m 120 dare a Mantled,
PatY CRma(wy may dispute of UN Rman,in
an lrreNavaok manner, i as by Magi. uonuoswml
CRFWTMN fARTAIRERN0.R
((jpgl'ONE ii khommi
An an b be wed as a mMalrwr for Me oemaW mmaem has MM WrRJ9M 1mm
and is denied as rollovre
Mae undermine Ter it Me um in mo small to had the anEm memated mmalne.an aMi4Mel MW i mmirmr may be used for dsGnry.
ore)®A Mum 'eM MpurSaesd lr ,nd mrsnd Tmumumis WuN ua eMe6omyd®1
�(V� fie Visa Cremalory yell phm that uemeeadAmene in
a Nal nmMr mnww M dNrmm. mn.au.n.mm
RdIeMGi µesm al
Tnis AUTwhetlon Fumwae gdvYedty __
CommssMab FumrBl Care, I
400 Wpla Ave Sffili Spmps MY 12W
and is shamed by Ue Nneml dirsclor as agrees b ib esacu4dn
Ii nave maived a Umarkind on"of this AU omart Fonn.
TM pamom(a)IdentlRM below,team Me pxson(s)In mn\ml M dYpoJdon.xTo by signing MW AU Won Fomn.abstis)
0Te suumay and completeness of Me InfamNWn<onttlnsd In Nb AuTmhatlon Form and vuTcynt Me tangoing.
Blgned she 13M day,of Bus, . gg
Yvanne Bhutan f A yl
g$ &aMiey $amb]e SpMS NY lZii
mii
WITNESS:
Polland G. time
11" tnnnmrwwim
maid
an Verged Gordon
same
OW-1i(Rev. Ni Page g W d