Dingman, Carolyn Pine View Cemetery & Crematorium
Quaker Road
Queensburyl NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOM,
.-__. RETURN TIME-
DATE 8 TIME REMAINS ARRIVED AT CREMATORY:
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAf IN19:
NAME: _ CARMYU DIN1FF'AIJ _'_CASE ITQJ7
TYPE OF CONTAINER: !14 y 4+tl;c- py ( lld
. y IOW �Q 1 M1 FFp
PLACE OF DEATH: K t704
ESTIMATED WEIGHT OF REMAINS 8 CONTAINER
PLACED IN HOLD: (�
PLACED IN REFRIGERATION:
DATE OF CREMATION: ��yA.H TIME STARTED: M TIME COMPLETED: I y
—�
PLACED IN RETORT: _ 'i:vAh meveD: _ 8 U q}t-
RETORT pIN WHICH REMAINS WERE CREMATED: 'RLy{-fbl('(,]' L�
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS L
FROM TIME OF ACCEPTED DELIVERY:
NOW:THE CREMATION LOG SMALL BE RETAINED IN THE PERMANENT FILETHE HE CREMATORV,
No,York3nm
�J NEW VORN Division of °"'°r"""`""'°"
J— ETAif OF OMLMIOFCFMETERIM
Cemeteries cideals,
flossy.W 12231U001
TOep ll'.IMal4robv 6
WvAldOarrywel
Authorization for Cremation antl Disposkion
Tb4 AUMar "M Form must be emn land sign" priers ENlvery ornmaim fMceam.
711 W020
Dnte.
Number:
Cremamy Name: Pine View Crematory
Quaker Rmd, pueempyry ryy 1RBna 51&]aiMT
Address. pip.
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation IS carded Out by plaang the remains of her de ai and the container holding the Rhyne into a nemaion chamber where
Metals sublmded to Intense beat and flame. The heat and Items will mimnh and module a gMing except bone and red1,
whim are an that will be he Offer cr ation.
Falanng cu m ille.Me vnmlpy well lake reabomme axare W remove an of m dd e remains a other material from the discussidiscussioneabon
chamber, but some minimal dust add re idue will likely day IN b behind. The chambers WII separam movidenbl and foreign material from
the rebel:and the mmental and foreign maned moil be dlspas$J_plas Wulr bylaw. The:amebaremalna Muberradardlaly
puNeMed Imo small PI¢ea antl plagdImo a dmdgnw1container Or urn. Cmmaudnmaineeamnllyampul"Hm untilm
single fragment Is r nivbleas sksl ltlyye.
OPENING OF THE CONTAINER
The oematoymayonlyopenthew Wlnff hOkling Me unvma human remains In IimI Grtumabn®s, sumwtomnmM
immty Wthedescriedw Wensure Matnc materiel Sande whichmighl Injureempbyeesordamage Meve MMPm If
human remains are Nlivered In a cwrtalnxwhich is reasonable mrcrema kln such as wmmummal or Mnml casket Me
mamry will require m Mat Me reain M moved bacon
Inch a Suitable consumer n It accent: alm.Me mm The:perry Of a
mnuirer or Me o-amler or removal a scheme wig be ma dusted before a whnea6 antl vnn daydone in privacy.with digray and season
IDENTIFICATION
Name Or Deoeaaed. Carolyn Dingman Married
Merilel Saturn,
tan renown Address 178 Lake Tour Rd, Lake Luzern, NV 12348
Place of Death, residence
sex: 17M ®F Age:63 DOE: 7/12/1957 DMe Ol :7/182020 Fsbmatwmgm. 130
(moonlit of ceakautlMlB.nm in v4sch Mans win be delivered.
McDonald Container, basic cardboard; no interior
PERSON IN CONTROL OF DISPOSITION
(Porsm(a)M m'NW ddlsmr2rn. �ffi QVEdXn/a4wMg1
I aunt are the deNgnated agent OMm dewaaed designated In a we or crude inslmmmwm led pursuant to Public
I hbaw Swm4201.
IM/e have no knowledge 1M the drnvsaN executed a written in9mment pull t0 Public Heehh taw Sactim 4201 Ora
M tinning drectom or the dlepodon M his Or hernemams eM lays are"Miam at having pri under Public Heats leas
Section 0201 and have Me nght W auome tl on of the Kmalns of the dew . situation M omhip SO Me dxeaaad bAs
mllows.
Carolyn Dingman
DOSdgggd(Rican ORr15) Page 1 of
Authorization for Cremation and Disposition
the mlmxrnS)
she understand that it me remains are notaaimM within 120 days Of overmuch.
Pone Wx Crematory
my dispose of the remand in
an inelnewhk matter.awJi as ur emuedng. urA�i
CREMATION LONTAINERIxRIN
NEta rem4owg) (��
Marc Used
arRse�a,crnW re ner her me cremated remains has Nun Orneased f �
aMisaemiWnd l wa�V
IMN aM.M.na inn mine wit isma.er.o m Nina Me enureammM remaim, an addiwrel ryla mmamer mar w aw,drwaxvwy.
-0R
An um is not yet purtna ed. IMb Un(Mebnd ill it no Our is pntlrareed!or Otherwise povired
Pone Vkw Cremmry
� wn�rl will plain Neaemeted remaW In
a dead IempoRry container for dellvesy
Patrida Miller
Thu AuthorWtlpl Farm Was crowded Is, was a uculed ad
la+vohammp
Brewer Funeral Home, Inc.
30 Chwch St. take redem4 NY 1]SW H4o
and Is elenM ar Me tunes director so serene tom evewgon.
i have received a composed copy oftf Authorization Form.
The peraoMa)iaeMMetl ENew Was;Ms pereardin In conshol al Mummition,who by sieuma this AUMereation Form,afbon
W Me accuracy and Completeness of IM In1wmhdmcin ainatl In this Authorization Farm and entrenched Me Israeli
synth 16 dorm July ,m
Dale Dinin gman
176 Lake tour Rd., lake Llaxre, NY!dada
MY-
WITxE55:
Perko Miller ` '�j\(fit!
rnme.n.mx.p
12165
Carolyn Dingman
o.—.oss
OOS-faeai.08115) Paee 3ore
1
Authorization for Cremation antl Disposition
pnmrc na'n nre nnbnw)
Numbir 2 Dep. husband
1, A rereon designated in wages,Phi lm PWk HyYk law Becyrm Gpin);
I The whines spouse
L. The eurvWirs tlwreeec warner;
a. A Surviving mmngceAtl eighteen annot years of age a olbir.
6. Asenow "bland
8 A rgaoarded,emen years INa,e or olCer,
]. Any p heparin eigMen were
eighteen ry oft a age w older enMleO m mare m me 6amkane who Ware eosea in releennanlp m 11p ae¢a9eE:S. duty
(Aerendntw retsina who the eased
a wntlen Statement Pursuant IS Public Health l.sa.'Section 4301M
10 AmlOher Hfiaml Oficarofa County,are pudicaEmidahatw enrolment purauanito the 8urrgNe'SCOW PiomEum Ad
14a' Any season eonwho is aces,on
Lee,sectlnnuot(7). eehee of thestemm re
ed and who has saekd a Sabah Statement passed asPOblm Heaigh
f /14 TNREE arms rarmwno
Vivo meRby Sam that the body Atha tereaaM toes not Semein a hardly binary wear, power ull, ratioa rive implant,
moemve dm'ice qp that any Soon mearlals ware rammed prim to the waromian of One A.Marfuton Fema. Million m Rmove
grebe IM1ms prmrm cremation may molt in harm he fie cramafory and preliminary Porwnnat.
IMb affirm eat irytructlpns have bass Owes m PeVpie Milky
waeNnq the removal aany peronal ,Pearly or minor thirp aveluewhkh my si2niry bNwr Or ion'
teeeexd wtane,to Pine New Cremamry y ry memeadee
prexrve.
is nM resparmmle for One mmosal of ceraonal hems has tar cCrhmner Ownor aspern Sol remain
s of this ed, P OmiX be In tlk
1{ Container Or with Me remains will be deaeoyat by the OM1mation pmgae aM omen be raei art managed
l '1 . IrWe M1mae✓auMMu Pine New Cremamry
( lcwvrrw
ace ate the happens a der dewaed.
Ft
The Mrsmam y m repress the cremged mmetm INCe tereaet bers tlw,crerrelmy an
& Fureml Name' Home, lnO,
indent 3a ChurM 8n., bike Wurre, NY 13hb
618916 2]H
phone
The M.mn H rly Inf ncy Cemetll bimswww aeakites.:
burial in Holy Infancy Cemetery
If far any rasson the wrwh named aWve does has aka rya m&the amnnm rename
Pie New ctNnnpy,
is aumornet to grow mea mn
the temanaro amwm Fureral Harty. me
hsvwgmxra,p by dowery
in pesson or by registered ma¢
Carolyn Dingman
WS18Wf(Rw dens) rsa+woa.�
Pape 2 of