Hutchins, Ronald Kenneth Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745.4476
FUNERAL HOME: kVRQ RETURN TIME:
DATE S TIME REMAINS ARRIVED AT CREMATORY: „ 7I gND II-V
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
rA 6AA RAff
NAME: FbMUn yonsiC CASE goo
TYPE OF CONTAINER: / e3ld 4Udod SI.,No-V hre4/ e 348L8
/� .
PLACE OF DEATH: WY A Hapf 1 II
ESTIMATED WEIGHT OF REMAINS b CONTAINER hr fM
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION: -IIII'ID
TIME STARTED: II yS TIME COMPLETED: W
'ZSV0 -1
PLACED IN RETORT: II HSIM MOVED: ILIAf`/ . taq I
RETORT R IN WHICH REMAINS WERE CREMATED: �n PAYt IF^^ll
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SHALL BE RETAm[O IN THE PERMANENT FILE OF THE CREMATORY.
4 ps amanmentNsrge e
Authorization for Cremation and Disposition
as,trmmM..elan. wbe .
clriba>uzaz
This Aufhorketfon Form must De "npN amfsWwdjk ar to dalval of romans torcramaaan.
Date: 7/8,170 Number QOD
removal Name Pine V Cmmetwv
Address: Quaker Road. Queensbury. New York 12804 Phone: 518)T45-04TT
CREMATION 1E AN IRREVERSWU AND FINAL PROCESS.
Cremation Is carried out by placing the remains of the deceased and the container holding the remains into a
exemption chamber wherethey are subjected to mien"heataM9ame.The heat ant game will addressee ant schemes
eyerychiag except bone and metal,which are all Mad will be left after veeaaon.
Fallowing crematlon, the crematory will take reasonable efforts to remove an of the remains and other material from the
arromation chamber, but some minimal dust and residue all likely be lest behind The crematory will separate incidental and
foreign maternal from the remains and the incidental and foreign material will be disposed of as required by raw. The
cremated remains will be mechanically pulverized into small pieces and placed into a designated container or um. Chamber
remains generally are pW zW all no[Ingle fragment Is expndable as didebl dswe.
OPENING OF CONTAINER
The crematory may only open the container holding the un-cremated human remains in sinned circumstances,such as to
confirm the identify of the decased or to ensure that no material is enclosed which might injure employees or damage
matory ,property, If human remain[are dalverttl Ina comtlnerwhl[h is raft[Wbblefdsremrtlon such as a mrtmmlal or
royal casket.She cremrtory wgl require mat me remains be moved into a suitable container before N aaeph She remain.The
opening of a container or the transfer or removal of remains will be conducted before a witness and will be done in privaq.
with dignity and respect.
IDENTIFICATION OF DECEASED
Name Of Deaeygdd1 (�sitivAA 1Y „U1fn o5 Markal SfaNs:Nyp{ awbal ate!
Last grazer Address-:rd-q i V. LF..``, rnnC.aS�! wl �aaslZ
Place` Aof�Death- GIP.y.ti S`KKill
�t 2Y
Sexy tlM OF Ages �^� DOe: ���(�i 157X Datedf h: a Iva+.._ EmimatedM iBM: A-1jIIK
Description of psket/container in which remains will be delivered-
Corrugated Cardboard Box with Plywood Summers Model a 1181
PERSON IN CONTROL OF DISPOSITION
(Person(s) In control ofdisposition,Initial ONE of the following)
am/We are the designated agent of the deceased designated in a will or written instrument executed pursuant to Public
Health law setting Q01.
-OR-
I/We have no knowledge that the deceased executed a written instrument pursuant to Public Health law section 4201 or
a will containing directions for the ionization of his or her remains and (Continued nexxot``Me) 11 ,,
`�ttl'l/r�A.YlS
barrel loz..Who xw.aaa..w.a hi
I am/"am the proommsh having priority under pudic Health law section 4201 and have the right to authorize cremation
of the remains ofthe deceased. W/ourrtWMtl pw Me detewd has felbws:
(IAWn/rom over brew) SO 1
Numbsr.�Descmxboo'. '-Je U—✓Y�
A Pelson designated in wtigrg pursuant M Pud'c Health Law wcgon 4201 (3);
2. The surviving spouse;
as.The sunning dWreNio partner:
3. Any survivirg child eighteen ye m of age or ober,
4. A sur wing pa ant,
,$`A Ig sibling sponsor years of age or older:
S. A lawfully appointed guardian:
T. Any peron(s) eighteenyeesofage orolderentltledto share in Measlate and who were doseat in
relationship to Me deceased:
S. A duly appointed fiduciary of the estate.
9. Acase friend or relative who has executed awiiden statement pursuant to Public Health Law§4201(7);
10. A chief fiscal officer of a county or a public adminishater apponted Pursuant to Me Sur0gate's Court
Procedure Act;
10a.Any Met person who Is acting on beeff aMe dawecetl and who has executed a women Nalement boosted
M Public HeaIM Law§4201(1).
llniEOIALL THREE of rhefcoming)
,dV i/we hereby affirm Met the body,of the deceased does me contain a batters,battery Peck power PRO, radisectives
implant, or radioactive device and that any won materib ;were removed poor to the execution of this Authorization Form.
FUlum to remove thew Hems pride to vmutbn may news In harm w the cremaory aM cremawrs Person"'
CZW t/We here by affirm that instructions have been given to Wv.fdvwr—,) casho Raflem#141M regarding the
re move of any personal property or other thing of value which any person signing be law or any family mere era the deceased
wishes to preserve. lremnm•o^pl Pine yew Cremators Is not esponsible for removal of Personal
Items from the container or from the remains of the deceased. Personal Items left In the mMelcer or with Me remains will be
destroyed by M ro e Rwndon pcess re and cannot be vleved after cosmetics.
c_.ryv I/WehembyasMwizekrewvvr, emel V' C wcmmge Mee mof
thedeceawd.
FHAtbs SIMN
The person a morlxatl to revive the command rerwins of the deceased ham the crematory re:
Name Baker Funeral H
Address: I I I supreme Shadest, Queenscogy. New News 1 Phone'. (5181]51oi3W
The cremated remains of deco will be disposed of as fWWvs'.
Return to family 0 be deceased
If for any reason Me person named above tloea clot rake(dPyMwRm of the cremated remains,
rywnnwvmmn P' V C haldhm¢ed M give possession of Me remains to
pureihivwm.H Bke IH by delivery in"man or by registered mail.
Rom, A
musrit I w, oVW um Nrv^wva r
le N&=Idmfrr:vv m)
.� IN urMerstandthatif Meremansarenotdeimedwbinl20dWsdf mMt n,
I�wmn.ne Pine mew Cremalory may dispose of the remainsln an lnetrievade manner,
sudr as by scattering.
CREMATION CONTAINERNRN
Potosi ONE of rot fnlbwlnp)
An ante b s used as a container forthe cremated remans has been purchased from Baker
Funeral Home and is deacribe l as burned,
Wye understand Mat it the um is too small to hold Me asks trembled remains, an add Urinal ingld container may be used
for delivery.
-iq�'�
IALM um has not yet been purchased. INYe understand that d no um is purchased or otherwise provided romnway
me) Foe mew Cremamry will place the cremated remains In a rigid temporary
mMamer he delivery.
This Authorization Form was provided by Amrii renernml fsssia PeHeMNlalO]
was executed at lN^ .,i Baker Funeral Home
Irvn+ano'n.eev.+em 11 Labri Sal 1. Oueensburv, New York 1200A and Is agreed by Me funeral director
as witness mils execution.
li have received a completed copy of this Autlerrization Form.
The persona)NenMed Wow Were the perswr(s) in sonbd of disposition, who by signing Mil Abdominal
Form, adest(s) fo the acoonal and completeness of Me iMprmafian contained in Nis Addronzaal From and
euNwize(s) the kregoing
Signed this dayW --Sl�l� 20aa
Skin"',
WITNESS'
Cassa RaRerN
ii sumw nvedmrveeu..m: runewmosgrpe
Funeral Horne Red NI130
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