Sherman, William Clinton Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: _ AgFL,VD _ RETURN TIME:
DATE 8 TIME REMAINS ARRIVED AT CREMATORY: hj_'aa'OM
NAME OF FUNERAL DIRECTOR OR REGRISTEREO RESIDENT DELIVERING REMAINS:
MAz1� OATdSN
NAME: W=u ah r. S�I})tpmAa JJJ_CASE aI
TYPE OF CONTAINER: FRw! iry�H I IN ��pRry
PLACE DF CN ArHI _ ib PN.r Shah RPf I UT.L« Ilji(r I'�J It87j
ESTIMATED WEIGHT OF REMAINS 8 CONTAINER_
PLACEDIN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION: _ � 7/RIz
TIME STARTED: , 7, 7o A1/ll TIME COMPLETED: 10149AM
PLACED IN RETORT; 1,30 M MOVED:
RETORT # IN WHICH REMAINS WERE CREMATED: QwW N119 TL
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 THE PERMANENT FILE OF THE CREMATORY.
` N11 YOM State
Mp Ment of State
NEWYORK Division of DIVISION'OF CEMETERIES
STAT[or c°mmene ajS°
°"ORL°"'^- Cemeteries II QN)l
"::DtN.,e al.e
miss it.,army
Authorization for Cremation and Disposition
This AUMonaetlan Pam must be Complena and Signed Prior b aenvery a ranni for cremenon.
Deis: 7i ziI to Number. gP
Ommetory Name: pine Yew Cremabnum
Address'. Quaker Road Chuseendbury, NY 1280e Phone: (518)7454477
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremabm 're rimed am Cry pacing the remems M Me denied and the comminer hadm9 the mmains into a cremation Chamber s OM
May are subieded to imense heat and game.The heat and name will incmenn and Consume everything except bone and exact,
which am an first will be left a rcremation,
Fdlowing pemahon, the Crenski will take reasonable anode to remove all of Me remains and other material from IM cremelim
Tamper, but Came minimal dust and ra ldue will likely INS IM behind.Tine cm Cory Milgenerate Irtcidemelfind foreign material hdn
the remains extend Moral and tomign matmal wail be diSp otas rc9ulred by I" Line cremated remains will be seasonal
plummeted into small pieces and plied into a designated Container or An Cmmand mmalns generally am puiwdmd undl no
single frpment Is recognizable as skeletal tWue.
OPENING OF THE CONTAINER
TinepemMay May only open m the ntamerhoMlig the un-crenated human remains In limited cirwrnmaueq such as to confirmthe
Nenldy of the de Oor to ensure that no matenel 'U enclosed which might injure employees of damage the Chira Ory pmmMe
human remains aredelivered Ina vwMlnerwMch is surdminble bremmanon such as caremonlal minimal chsket Me
mnabry welly ulmMat Te remain be mmved into a euWble codinerbefon Naccepb Me remains.The opening of
Container or Me tamrer of removal of remains kill be Conducted make a vaned and vfll be done In prlrery,Win dignity Yid mend.
IDENTIFICATION OF DECEASED
Nameomemasdd William Clinton Sherman Maralsnlum Marticd
Last KnownA4Gress. e0 Roor 8 Hudson Fails,
Plemomeath 80 Raver Street, 80 River Street Apt 1, Hudson Falls NY /y'' �
Sex,M MJM F Age'. ]0 WB'. 0211L195n DMOdD"M: T MO Edmamd Weigh:yza)
4sulpfim ofwsbik ner In wads min "Wit be delivered.
Ml (•..r-r.N I trued �7 ii hy'
PERSON IN CONTROL OF DISPOSITON
(Perscnry)IncmlMOldapesWon, m_aIONEOIMebIbM
I wil are Me designated agent of the deceased designated in a will or mftn instmmeN executed pursuant In Public
Health taw Si 0201.
-OR M�(a
/�tjj IN✓0 have n0 knowledge this the demised executed a wsilnn Instrument pursuant IO PUNIC Heaths taw SeGion 4201 ore
Il connimmE all arMe itISWBMon of his or Herfemas and Nwe are the personalhaynneoity rom Public H Sash Lew
SeSection 4201 and have Me hght to eutMnze Gemesc of Me remain of the des Od.WMur In rtMp to Me deceased is as
ronmw
William Clinton Sherman
Mwmapearrll
DOS-1591"(Ray 08115) Page of
Authorization for Cremation and Disposition
ral M1an Me rat below)
Number. 3 Description' s
1. Aperson deaiBneted in wn6iq pursuant to Public Heats Lmr Sephici 1(J);
2. me aumane spaces,
20. the forming domestic partner,
g. My surviving cold signal years or age or older,
a. AauMnne parent',
5. AeurviNnesibling eighteen years of age or Siam:
B. A lawfully,appointed afternoon:
T. My Postal eighteen years of age or older ar tiro sham in estate and who ishm doubled in relationship to deren ;
a. A duty appeared nducian of estate:
g. A does Mind or relative who has executed aw ii nstatement Pursuant to Public Hanson Law Secdon@01Of1
10. A debt flecal oBker of a coumar a public administrator appointed punuen110 the Surrogates Court Proposal Ad.
108. Any other person who is aching an behaH of the deceeaed and who has swapped a written statement pursuant to Public Reach
Law Section 4301(9).
( K I A THREENMehWymnal
Arm hereby affirm that the body of the deceased does not coMam a batten, Same pea,power call, radmadve Implant
orrdioadrvePeace and that ary,such materials were remmued and to the scandal M this AuOW aOm Feel. Fallun to nmi
tlxae Hart army creme0an may mu It In harm to the commissaries!Manuel penennel.
�mem affirm Met tropospheric have been given to Mark K. Pi
regal the remawl Of any Personal property or mlrenhire of value which any permed signing below or any family member of the
deceeaed wishes to preserve. Pine View GremalRium
sperwardi
is not responsible for the remmal of personal items man the Wneioer 0r from the remans of the demanded. ftmonal Ism'Its In Me
contomm'�'IIItpr or WIM Ore nmalnt meld be de$Myed by Me whmmon proposs and cannot At Mtl d Inner mmanon.
hWe hereby sumodu Pine View Crematorium
to create the Mmine of the Maeeud. rimer
FINAL DISPDSITION
el�'cee to receive Me managed remains Of Me deceased lmm the v abn is.
Name'. h 14 r rf
Addreas � {Ma4 c1 Good, QI . .Vi�2e35 Phone: (5Ib) 747 frtsi
Rq cremekd rerneins of deaaeed will M disposed of me former:
Es,i
Bt sit I dp URkv.
It fa any method the prawn nomad a com does had take po musion of Me ammlerl remelrs,
Pine VlNV Crematonum iaeuMaizedwgwepwenwo
tmremalosto c immoral
in person or by regMerad mac.
William ClirHon Stephen
DOS1BWf(Rev. 03115) m++wo� Pal 2 Of
Authorization for Cremation and Disposition
mro 91
anaern.ndthatdma Means are nat.imed within tzg days of assurance
Pine Yaw Cmmawdum may dispose of the remain in
annreoievable manner, suth as by amended.
CREMATION CONTAINERNRN
m_M1e awe own9—
An um to be used as a mnWnerbr the amended remains has been Wrcxased M1pm
and is described ea better
Ii understand that It the um is bo small to held her arts,crested remains, an eddltbral rgN mntaiirer may he used fw delivery.
-0iq-
—4LAnum lsnotyapurex8W IhNeundemWndi lifnaum4pumhaaedwoN ml/ pmoded
Pine Yew Crematerium And pass the cremated remains in
e rggb p mM mntaimr for delivery.
This ortr on Form waslannfir by More K. Perish wan execti at
ffsavelarkireftwe
Carleton Funeral HorM, Inc.
BE Main St. P. O. Box BT Hudson Fells NY 13839
and Is signed by the wrerN mercer as wnners to is emmi
i have reUrt'm a completed Wpy a this AumsrYaum Furm.
The persons) IasrNtnad below Iwre Me penonpl In warrant mdisposigon,who by signing this ANXorlurbn Form, atbstle)
b Me accuracy and compassable m eteInfomlauon remained In the Audrwlzation Form and aM zelet dw foregmng.
SignedMet dry ofJUIY . to 20
Benhamel McPhee ")IjNt'�
Poi St m er
Qpkll-
6 Po eel Hudaan Fells NY 4839
rarewmwn
fears
.y>awww,.
"Tandy
Mark K. Pariah
r
WNI Mh Cainton 8hMman
DOSte9bf(Rev. 09115) Paga 9 M8