Thomas, Marion Pine View Cemetery & Crematorium
Quaker Road
Queensburyl NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: IID K Ate_ RETURN TIME:
DATE A TIME REMAINS ARRIVED AT CREMATORY:
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
le4a vtfmm
NAME: _. PAf.LEA) p(Ulgj __CASE p _ _
TYPE OF CONTAINER: ��1n E64 lkL y bD/6RF� /�l
GLACE OF DEATH: L
IT'S Fu vdv� I Aki. RK µ1 lzdarr
ESTIMATED WEIGHT OF REMAINS A CONTAINER 170 IM
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION:
TIME STARTED: _ iWM'1 TIME COMPLETED: � Z�7JA
PLACED IN RETORT:
RETORT A IN WHICH REMAINS WERE CREMATED: $YP(.{( O..c: NAC
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOO SHALL BE RETAINED B IN THE PERMANENT ERE OF THE CREMATORY.
oopmOemnastale
ST YORK Division of DIVMI ass cFMERRIFa
fj OWORONFNrty. One s1ommau R$M
Cemeteries M °
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Travel:Efid4 ea2m
Hamm°
Authorization for Cremation and Disposition
T %AUNotln Farm mustb compleYp and tlOnal Near to delare l nmalne for
CMMgM
Dow July 10, =0 Number 8 r
Crematory Name. Pine Vkw Cmmalcry
Admen. 210wMrRM. Ouwnabury. NY 12BW PMM. 518-745IO7
CREMATION IS AN MREVEni0a AND FINALPROCESS.
Cremallon is erred oNEMp ng the remwny al Madame 1 eM had wnUircr hours the remains into acmmatian chmberwhere
lheyaresubletledbirlbrwehealend Mme. The Mat and Memo was lnclmnb aM consume ewMwm eeup[boom and mMl,
which an all thativi M leM ronmai
Following aematian, the cremalpywill hike reRorebk eflome to remove all clthe remains and other mabrel horn the cremation
chamber, bN some minimal current Mldue will body the left behind. The rAmatory will sua2m IndWnial ads foreign material Mom
the remains and Pe Inckamal and malign materiel MII be deduced olds wall by law. TM cremated remeinawlll Mmechenimlly
puhenxed iMo smell pis and plaintsirb a Montreal fortifier or urn. CmaWmmalm QOr lyem WIwr untino
Jn0MM1e0meRN nupnlubM u°Malebl ilwus.
OPENING OF THE CONTAINER
The oematwy,may only down the cmumer holding the astronauts human hemema 'm limited circumstances, suG ea m median the
i]enMlyathetsecNwd or Is made that no material s Mounted Mach mi0m Iniure employees erdamege fte cremations pmpam. It
human remains are dellwnd In a container which Is not suitable for cremation such as wwmenlal or resmal u°ket the
rem gMll sequin that Ma remains be moved Into a suMbb,royalmr Mrore It accepts the remains. The owners; of
¢nMnerOUe transfer ormmovall olmmam will M commdi Mmre a wenus and wall de done In minor, vnth dignny and meemot
IOEMIFICATION OF OECFASEO
Name of Destroyed. Marion Thomas MCInH151adv: Naar°LTm
Last mn Addict»'. °owt Forvmo]Ortn South, Clifton Pairs NY 12CM5
P4c¢M Reah,. Mot Foxwood Oriw Sotto. Clifton Pairs, NY 1205
sea' OM OF Me:96 row 5/3/1924 omwo..m'.07l1&2020 Fatknehid ve0lm 120
DBBcrown of caakemormmer in vhidt retains vnnM delivered.
Minimum Cremation Casket, Florence Casket Co. Caldboar illyine
grab IN COM0.OL OF DISPOSITION
lPertdnlsl m ronirat ordlspwmm�, MIME ONEd me aMirgl
I amM4 any the command agent or that dKBBHd LWgtutml in a will of wide Inshumea mtwi pmsueam Puma
Heath Lu:Betliu 0201.
OR
w' Gy Von have no universal that Me tstceaW endorsed a wriMnlm movement pnrsuaa todan Public Hearth Law se a201 or
n mom mmg directions for Ise diuremon of his or bar remains eM Ito are the persons)MNrp twenty a hear Public Haulm taw
small 4201 and haw me hill awhonae gemadon may rememe of medemusd *Murmlamnehlp W Me dacwssd Ism
mix
Marion Thomas
wwww
DOS-Ithasta v.Mao) Page i of 3
Authorization for Cremation and Disposition
firm"from Has eat be"
Number 7 Besrom Nlehm
t. A berson deslpnamtlln eaNy purwaM W Pure¢HeOM lsv sactin 4201
2. The wrvlvrw ewux;
M. The son,...q mannumc peMer
n My welly mW eghwn years of arse or other;
N Arvniving pamnrl
!. AauMnnO sibling Nomen"am of ape or ode[
6. A lawfully apron]guaNun.
T. Any Mmon(a)WhM nyears of ate or 0ltler enNbE to Nara In Ya wd and was teas do" mYWnsbip to May, el
a. A duly apainlN fdu=m of the xtam;
9. Atlm dwdd arehass way has Seasonal a wntlan st mMWrsuant Y Publle Heats Law Bxdon 4201(7),
10. A aN foal afixr of a ci ty V a putrid abnormal appol and punwnl m the 6 mergers s Ccurl PrtMtlus AM
1W. Any Inner Anon wfio N San on behalf or Na mNasN and whe Ms Real a when smYmerd moment Y P unlit Health
taw SWUM 4201(7).
(moLL d A THREE of Me YRwinp)
`L
CT It Moos eNrm NM Me body of ore l W days net mMeln a briery, W"petit, poorer call.mftwtrB'mal
w radio fivedeal and Nat any Such mMnals ware removed prior Y Ne Shadow or this AumoNa Foom Failure Y remove
` Mew Items wor Y cmmallon wy result In he me of Me crx q and
cmbry xmonmel.
,y At 7 Whe affirm that instructions haw been given Y Table 0. Kilmer
1\ re MiN the removal of any ayrawal ryc or olfrer MIN ofvalue which any ay nw lag Andy or any merry member oftle
demaxd wishes Y pseerw. parev Cnmabwy
la nor ras[axlok Mtlro newel arparsMel llama mom Ne mrblmr orhan use lwnain of NademeeM. Parsan.I Imme mX In Na
di
�o/n�Yln�arorwlN Na nmsine will bus CxtrayW by Ne cmnMx pxw a"cmml be reVNved eMrcmnetlan.
LYN M1arooyauthMx Plneflew Crematory
Y cmmsb Me YTslx IN Ne daxwatl.
(rINdtl OPTIONAL)
Man;Mmby auNodx the named funeral director to provide Yr delivery to amid csmatlon oy an sXamM
wtoryIf0 med xcxeary in rear opinion of the mineral ilsstor,and Y area"this form to pmvlda the correct name and
addms of al OW mms q.
FINAL MSPOBITION
The Nmn outhom Y scats to aememd remain of Ne l gx from me comalay by
Name: M B. Kumar Funeral Home
ppdrey. M Main Stmat AgYle, NY n2BW Phone. StaE38d218
The CRmamd remama of demmal WI na dlaeaxd Of as Idloxe
BUMI at PM$i Hill CameYry
If M any span the person named abuse days nN rake paeeedm INN6 aemaW mmNrd.
Imme lmw Crsmatory is auN Ya"po 0
owmrox
Me smaina to al Kilmer Fum How oydeXwry
weW
in pecan or byr sy ni � �MNonT omx
DOS-1 g t(Rev.0,12N w� Pp2of3
Authorization for Cremation and Disposition
(�me muothny
Y��Iwet,manMmmnnme em.inn.rerblmim.arnmin ,mcmma.meoun.
Pim uew cramatoly may answer order mhaiwm
an nationwide manner.wm as byacamnrq. ✓Cm
CREMATION CO AUNEriNRR
it ONE of fhe moment
An um to bar used as a container far the crowded rem ales has Caen purchased from
and is 0pcnbN as firm
INIe Understand this if"wn is coo small m hold they years oemateJ real an adallonm had comir rmy used ROMMany.
-0J�vu�y
fa�M um 0 rKKyM WrNasN. IMb urldmWq met ale um le WrMeW or Werxmga Y1
PNSYIawCma4ry WI plop For showed remains In
Wuaonwry)
a ril elements wMemerf rdelivery.
This Aamoshetlon Form vas promised by Toad O. Khmer was executed at
M.9. lather Funeral How 6wxwurtwwn
�wn xuw
133 Main $trial, Prayle, NY 12000
and is signed by the Nneml dlmda As visible bins executio mmmrua
Il Mw worried a conpbled wpy of this AnesthetWn Form.
TM psnmp)IdsnVPW below Mlare the pervards11n control N dbpaeilaw who by allied n8 this Aam athimon Few,awl
m has attua[y and CompganeN 0 the Ieformaaon COnMIMd In this"whether Form add sumodvts)ma bnaobq.
®ynalim I day m July p30
Idnda Tmam -752�
4401 FomcW Min South.CYMn Park, NY ISIMS
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