Grow, Ann Shirley Pine View Cemetery & Crematorium
Quaker Road
Queensburyl NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME:
RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY; , fibrl"
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
449y VT I MFD _
NAME: _ hx#t l5804
TYPE OF CONTAINER: i4a
PEACE OF OF DEATH: __ MAf H kllMnyl II
ESTIMATED WEIGHT OF REMAINS S CONTAINER_
PLACED IN HOLD:
PLACED IN REFRIGERATION: IP,a
GATE OF CREMATION: 7/wlj
TIME STARTED: ID 0 AM TIME COMPLETED: p� WPM
PLACED IN RETORT: IL� Rn MOVED: III i111 Q1
RETORT N IN WHICH REMAINS WERE CREMATED:
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN AS HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION we SHALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
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Division of wOFCEM IES
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Authorization for Cremation and Disposition
This AuMoza nForm moat a Complwmd and Signed prior by eelmery a MMal my for ommamn.
Dow Judy 17.2020 Number %6
Cam"wme: Mm V W'Cmmahry
Pam. 210Mker Robe. Guarneri NY 121SDa Name 518-745N77
CREMATION IB AN IRRE RGIME AND FINAL MMEae.
Cmma nisdemand oN by plearg Me remains of me dewsw3 will they wMairm hoMlrg the remans Info a ideal chamber wham
Vqy was whlecW mial heat and flame. The M1wt and Mmsbell lmmx and cmauma awryMing eacpt Sow and wMh
which am all Msl will Ge Me after cremsalon.
FcllownScremawn, Me crematory will awe ma ads ePOMm handrown
II of"remains and other material hom the cwnpon
chamber but awe minimal Oust and resl0ue will IIXey Fs left FMIndThe Mrywillwparate IndEentalandbrgnmMmiMan
Me remain and the mode ual and foreign material will m dmal 0 as reguitm by Inw. The cremated her will be mecnanl®ly
pulwnmd Nm wall gedss and ptePotl mto a d"gmW consumer or um. Cnm W remains gwwnlly an puMMM und!M
single hpmaa IS mca isiv64 a$sbWal Ooue.
OPENING OF THE COMAINE0.
The barrel may Phil open Me wmeiner holding the uncrem human remains In Imund circumstances, such as m ways" Me
idarMy of ter dermsed or M ensure PM no malenal Is entered whist night nrym employees or damage the cwnMry pmraRy. 11
humanmainssndallwmdInawnmlmrwhkh IsnasuMGNhwmm$OonswhmcemmonWlormMUI4$ LMG
,noroMIIrpamm Mmmalot Gsmovedimoasu wnblrlM Wdms dw Memalwi Thea42Mas
Cpnleiner or Me deru(er or mmoval of mneinwill M wnduckd Gefwe a wNAeeend WII be ewe in pnvary,wiU Ngniy end magcl
IDENTIFICATION OF DECEASE°
Name of oeceaed. ham Shirty Grow Mental Shins: dwi
Last Known Adders, 85 Glkhriat rul PA EN, wM NY 128W
P4001 Dean Gkm Fall Hal
For Do IMF ails:70 DOB: 06/23/1950 DM of rem. 07/151 EMmmdghgh;re 110
Dimensions of mskWwMiner in whim amain Pall be alry d.
Minimum Cremation Casket, Florence Casket Co. CerdEoard/Pine
PERS°1J IN CONTROL OFOBPOBITCN
Pwwoz(w In deal unendorsed B ONE ordre ldbxMg)
I ani are Me Magnamd Awe IN Me bettered dmgmmd in a will wx+IMn Inn umem ewNM purwal So Pudk
Heath low modern 4201.
-0R
C — bow have no knmNedger Mat Me ddOW executed awrtanInsqumem pursuam to Public Health law Sweden Q01 or
wall walling directions MMe dnposmon of his or her remains and Ind are the gnonls) hang worry under Public IT"Ind Law
saeden azm and nnw Me rgmm auMw¢e drematirn of the remand anwaecemed. Nynur misMmhmm the LwpeM has
follims:
Anne Shidey Grow
DOS-ageaf(Ride Dow) Pete 103
Authorindon for Cremation and Disposition
nwrtabm me emlaw)
NmmerB pspryliOn: MyeurVrvinO dllW 0gt0yn"am of al Or older
L A OBmn designation wriung pursuant m Public HMM Low Section 43oyST.
2. That simmng spouse)
L. Tro annoying domestic mal
r. Any morning chill eighteenyearn elope or older',
a. Asurming parent
& A annoying among Hmmen name of age or older;
0. Areal appointed guardian'.
i My Poreorms)eighteen years N age w older mWed to manam tlp estate and wMiLam dOMt In relamnMp to tM dement',
S. A duly appointed mul of me mar ,
S. Ado M1ierd ore&albs arm M1eB executed a wmmn 8tetwneM pursuant In Public Health Low Election 4 1(]1',
lik AMref fiscal or of amuMy or a Public admini Weppoul pure i to tlw 5unthare S Loud Procydure Ach
IN. Any char person who is aches an beMlf IN medema and wed has secured a wdmn aladmeM pursuant b Public Hei
tare Section 4201(2)
prodUALL THREE of me to OWV)
6 y" ' IM4 herWyefirm Met Me dray MUe deaemed dma no[mMeinemibry. oaXey pad, pmrerrell, radlOecXN lmmed,
crmdi0%nve devim and let any such ordemh were rFnowo poor b the exmmn acres Au Mza nFarm. Fallurebramove
N x� M%M$polar try cmmatlon may result on harm to Na cNMb m ry and cmabry pe
rson".
IS C Ask Who that instructions Mee Mel give to Talks Kilmer
rryeminB the removal of any personal Pr 4 Or Other Miry OfvyW wbiM ant person coming Wow orany family member 0 ft
oeuaud wlaMsbmreeerve PIneY Crematory
Ceti wro
is not mponaime for the removal of Noymnel items from the concept or form form the remains of the oemal Personal X sNit In Xx
cominsr or vi Ma nmal m mall the d"4 *d by Me cnmamn pram and cannot p re daMr cmndon.
Mnby euNorka Pine Maw Centelwy
tenor .0
b aromatic Ms remains OF me McusM.
(MAY OPTIONAL)
lMe Identify suthMu Me named Nmnl dlrsMrm provide for"leaer ofand cmmamn by an aMmi
(nomatory. Xdeemed neceuary In Me oplrn m of the fuunKKtoq to l dl and a m has
s M m to prevails an correct name and
Warren;of Me b 21WMW cumatery.
FINAL DMPO81TICN
The{amen aiAiu MHaeive me=mm remains of MC deceHud Rmm may aeme Na
Name. fA.B.weer Funeral Home
Mdrm 82 Bm y, Fort Edwam, NY 1283E Ph", 518 747 M
The mma remains ddemmed tell be d6yua of as fdkm.
Retested to Gamet Gmw
0 V any,reran the person nal aW deals red does maeaWw desds mmmMd mail,
Penn Mays Crematory oauMv Ngin pmeese'onOr
year
tlNT a,s to N.N Mher Full Home by ddfrery
on mail Or by Wm dmall rwvxewArxmS it Grow
Authoriution for Cremation and Disposition
fl�pal Me Aftivi
V C WJe ommostana had it No mma ins art mr wa 1 NtV& 120 days of monsoon
Plwuencrematory may shadow atlu demands in
` "'"w"'an Moneeaele manner. an& Asey sho erm;
CREMITION COMIINEMRN
(f¢ylgl ONE ofMe Joint
An um M to MW as calbhmr far Me oemeted demand M1m Lon purchased had
am Is desc i ed w follows
Wy undeRbnd tnA if the um N too mall to MN Me snore oemtlM remain , an small n8N oTltircr may W used for chn .
'OF?-
It. C , Mum Nnm yet Wrchesed. IhW undwtand Mal i(m um la puMaasd aratM1enr'ae provided
PM VIrachannal will place the cremated mmalns In
manewcwvn
a 4d hamodary cons!na far Memory.
This AuwMNWl Form was anoi Gy Two Norman was executed at
MR KAmm Funeral None dune+wxvww
rr~vmW
83 ethanol Fad EdwnM NY l2a28
and I9"i by the weeral dlnaur as moll to an eaechason w
Wh hew diamond a complained mew ofM s AuMomussam Few
The wrswts)Mentl hNax Whom Me pomontsl In shadow!ddlsphad ,and Ey signing Mls AUMo/trerlw Foam woo l
b Meawurwyandwmplarenw Wa lamAoncontAwin MY owdown FomlandauModzgs)MslowgolN.
Boned Mls t]M day of it .30 R0 u
Gordon Grow
115 Gi Nil W Ed, NarlbN. NY 12830
Gtl rP �gv.1Eu U��i�- ✓`^� X
deal
NTNE33:
TWtl Kilmer
11979 dmunaf Irruery rnan
Mre Sterns Gros,
prwavesw
DOS-I Sol(Fill MD) Paso