Bartlett, Barbara Pine View Cemetery 8 Crematorium
Quaker Road
Queensburyl NY 12804
(518) 74{5-4477 or (518) 745-4476
FUNERAL HOME: �IfLtFv RETURN TIME: 4.,
DATE S TIME REMAINS ARRIVED AT CREMATORY: 7IS(IO 1' eh
NAME OF FUNERAL DIRECTOR OR REGRISTE UED RESIDENT DELIVERING REMAINS:
p,,
Pa+. a <V.1iq
NAME: 61109A AgE19 CASE It gp?
TYPE OF CONTAINER: [� Y'
MII(UYA/A U'hTPr of elizo eo µA
PLACE OF DEATN: 1`H W OWN All&, GI ani
ESTIMATED WEIGHT OF REMAINS S CONTAINER I16 Ar
PLACED IN HOLD:
PLACED IN REFRIGERATION: � ...n,
DATE OF CREMATION: I� t' i 7k (1O
TIME STARTED: -]:O) An TIME COMPLETED: Q'{
Q�yIMy,.�
PLACED IN RETORT: l'b� AR MOVED'.
RETORT p IN WHICH REMAINS WERE CREMATED: F /
SVEA WEILAAk „ 11 //
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 VHE PERMANENT FILE OF THE CREMATORY.
Depanmms aisu¢
EWroaK Division Of O1"e1OH Of CE99 ""on Ann
aTATrm ComamH.n
Some "'" Cemeteries NY 12231..(atm4r4:aeec
Authorization for Cremation and Disposition
THIN AUM "on Form must be wmplN and alynae prior IN delivery of remalne for cremation.
om: IIIIw eumbec Qa2
Cremamrp Nme: FINE Vim Cremamdum
Address. 0uaker Road. Oueanswry NY 12804 Pdm: (518)7454477
CREMATION IS AN IRREVERSIBLE AND MML PROCESS.
Crarrestion they am uibl dmiMense hinge d flameacing the 'Sb Nat and Nin Rome d�d e will lnclned the einer r andiwpmM ems"n in camel�meurnevervithal
aml metal,
p eacap
which am all Nat will N left afar cmma0on.
Following crennumen IN chemtlary will take me¢onable efforts to remeve ell of Me remains ad other malarial from the me on
chamber, but some minimal dual and realdue will likely be toll behind.The anmetory all Accurate signal and bmignn dal from
the remains and Me lKidemel and foreign maledM will eve disci of esgguiwI by Neu.Tin aemabd remains tan be mechanl lry
pulvmaed Into email pieces and placed into a devigneled contiimr or part CmoW mnalns pemmily an pulwe duMl NO
single fragment Is recognlaable as skelem Xnuf.
OPENING OF THE CONTAINER
TimTbe crematory may only often�motaier holding tna uncremaled human remelns in limited dreumabnce¢, such as b=fl m Me
tentiy of the deuced or to ensure let no mMl al Is enclosed which might Injure empnyees or damage the oemmwy pmperifH
human remains am delivered in sroman..which b not suitable for cmmadon such as camenn let or rental casNth
mstmy will require Mat the remalm IN,human! into a notable container Nfom Itaaepta Me remains.The opening of a
menteimr ,or the trensrer or removal o remains wil be conducted before a Mtnem and will be done in proof wM gives,and respect.
IDENTIFICATION OF DECEASED
NemadDec W. Barbara Earth MarNISMIus: VJldwleE
Lan KmmnMdmu: 18 Riverview 81 Glens Falls NY 12801
Plamofoeath FORT HUDSON HEALTH CARE FAC Upper Br "ay. FodEftaNNY iZr7r5
Swc[] M ® F Age: rt DOB: 191101048 Date ADei 07 w020 Estimated weigen DIbS
Chu mpnon of askeuwnuiner In which remains will be deflected.
fAwBaP140 ILdCP N' ((� MrcDOrko �'r�' 1 PERSON IN CONTROL OF pISPDSI110N
(Porson(a)in unhd Wdwoaidm, iniflalONE orMe MlawingJ
I amNJa ere the Musics la]again of the dett8i d Qnaled In a will or wrNen Indument executed pursmm to Public
Health few SAmW 4201,
°R
* i have no knowledge that the damaged Mewm]e Yemen Innrvment NmuaM to Public Health LAN Bodion 4201 ae
"i 1 no diRNona for the diewshbn of he or her remains seat have are the parsoM¢) having frnmily under Public Health Lau
Section 4201 and have the right to euthanxa U alion 0f the remains o1 Me d¢msd.MaOur Matlanshlp ON Me daoaassd is as
follows'.
Barbara aaNett
(w+earosanry
DOS-1O91(Rev.08115) Pagel 03
Authorization for Cremation and Disposition
(iona mrheke Ce w)
Number: S Descmption'.
1. A Person designated In writing pursuant to PUEIIe Heats Law Setlion4201(0)I
2. The surviving spouse;
20, The surviving domestic paMBC
0. Any surviving child elgMeen years of ape or older,
4 AsurvlWng parent;
6. A wrvbing sibling eighteen seers of age or older
6. A lewWlly aPixynted guardian)
]. Any person(q eighteen more of age or older emitted to share in the estate and also Were closest In reoftnsNp to the 0emesed:
B. A duly apminted toupees of the estate
S. A claw Mend or relative who has axeoMd a wntlen tl Iament pmwM W Pubic Health Law Seripn 4201P);
10. A&iet fiscal 0lhar M a Gordy or a public adMdieralor Nepalese pursuant No Me Surrgab's Dun PMtt Pm Anil
toe. Ami person who is wine an behalf of the dewuad and"a has emcWd a wri0m statement pursuant to Public Heats
.ew Satlmn 4201M
pMtia All THREE of tlw/albwingl
IMr,hereby am=that the body of the tlettabad does not domain a battery, battery pock, power cell, mdloacme implant.
of hard Nre device and that any such materials were rammed prior to the eaewate of this AUMormos on Form. Fellun a remove
Merely dome profs cmmmon may reace In harm a se cmmesry and cnmatary pneanml.
-oiIM/e of tbalinsrrugsns have been 8iven to Me* K Pariah
regarding Me removal of any pemonal pcPerly or refer thing of vase which any person signing below W any family member of Me
deceasedwishestopMume Pine Yen Oremeanum
is not responsible for the reredos of pmsonal items ban the container or hqn the remains of the deMW,Penoni 1"9 WIN In the
mMyW nor or wife Me remains will be des"d by Me cnmatlon pr S and men not be retrlewd labor ommatlary
4-11 M1amry auMorae Pine Vlew Cm par
to comas Ma remains of the demised.
FINAL DISPOSITION
Tlmgrre�m�iFat ann prZ W ho ise the assume remains of Me decea
sed Spur they dent"la
Name: 4 ri
Address: VA aggst St 4#.1aa.nl. 0 I'm Phone: S0 'l yl-eft
Tim cremated remains of produced will be mspomd W as Slkyu
c _ i r
If for any mason the pesson named mews does not take poswaion of Me cremated remove.
Pine Yew Crematorium isa orlsed Wgivepoeweionof
Me remains to G Home n bytlYivey
In person or W registered mail. pow .vumr
Barbara BMbR
DOS-1898 thou (X/15) nu^• Pegi
Authorization for Cremation and Disposition
(manner Me,element)
INJe unMstand Mat it Me remains are nM seemed!whin 120 di IN Wmellon.
Pine View Crematorium may salary of the remains In
an lrtaraade manner, wcn as by etadetlrg. "^Worm
CREMATION CONTAINENORN
B�
M um to be mad as a wrAamer forms cremated remains has been MiUesetl from
and is desmbad as bIwm
Me understand net if the on Is too amml to read Me entire clammed remains,an widening rigid container now be used for delivery.
OR-
An on is Me yet purchased Mile trimmers MN Nno um is Wrstased or olMMse provided
Pine View Crematorium win pkw the comment remains in
a sas simpanarf cogsmer Sir dmNery.
This Authorization Form was provided by Mark K. Paneh was executed at
Carleton Funeral Home, Inc.
88 Maln St. P. 0. Box 5T Hudson Falls NY 12839
and is signed by the kernel deMm as witresae Its execution.
IM'e have received a completed copy of Mi$Ar or aDon Form.
The permar tst ItlmngPod below Islam Me pareOnfst In control of dispom0aq who by signing this Aumodxafion Form, m1Nae)
to the accuracy and completeness a Me Infommtlon wnbleed In this AUMor Ve n Form and auMaWts)Me foregoing.
Signed Miv OT day of JUN . 2020
Stephen BarOeq
CN MRow anal Staffing, MA 015"
WITNESS:
Mark K. Parish
� p
BaNara Raman
MS-18g f1Rev. O1I Page 3ofa