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Werner, Charles R. Pine View Cemetery & Crematorium Quaker Road Queensburyl NY 12804 (578) 745-4477 or (518) 745-4476 FUNERAL HOME: _ R� RETURN TIME: _ DATE & TIME REMAINS ARRIVED AT CREMATORY: NAME OF FUNERAL DIRECTOR OR REORISTERED RESIDENT DELIVERING REMAINS: NAME: _ IACAPC i.JEeMFQ __CAbEp �_ TYPE OF CONTAINER: F/l Kn(( PLACE OF DRATH: . ESTIMATED WEIGHT OF REMAINS a CONTAINER �QO PLACED IN HOLD: PLACED IN REFRIGERATION: DATE OF CREMATION: 7 (zz im TIME STARTED: I "I P/(I'/ TIME COMPLETED: 2: FF1 PLACED IN RETORT: .YI MOVED; 2: M z:yp0Y-7 RETORT 9IN WHICH REMAINS WERE CREMATED: SPFG PowE AV DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS FROM TIME OF ACCEPTED DELIVERY: NOTE THE CREMATION LOG SHALL 6E RETAINED N THE PER M NE T FILE OF THE CREMATORY. DepernmMMSYN sNEWYORK Division of DIVISION OF.Era TTemas NATLOF when Cemeteries en'°m,°,,,;xo; Teiep me'.151914]a6226 Authorization for Cremation and Disposition This Autlwtlaallon Form mustpa completed and slgrwtl primov delivery of remains for emmaton. July 22, 2020 Numbs: 451 Crematory Name: Pile Yew Crematory Address; 21 Quaker Read Glastonbury, New York 121pe phone. 518.745-Ae77 CRENATIDN IS AN IRREVERSIBLE AND FINAL PROCESS. Cremerim b chance out by deong me remains of the decea¢N aid gw computer holding the remaire into a common chamber"am toy are suceseed b incense heel and flame. The beat and florae will Incinerate ant censures everything aswpf bons and annual, which are all that will be part after cremation. Following Oemation,the monarch,will like Membane eXMs b refuse all of the seemed no and albs normal from the UemeiOn chamber, but some minimal dust and residue will likely be left behind. The crematory MII answers Imudemal and fanner material from Me remains and the lnpdenfal and lower marginal will be tllswxi of ayrepuiRd by low. The memaled remains will be maM8nkally baseball into small pens and paatl into a whowarW container or um. Cm atetl mmains genamity an Wlveneed until no single fragment N recognizable as clothes throve OPENING OF THE CONTNNER The oerim ory may only open the container holding the unSremated human remains in limited ecru msance¢, wdr a5 b wnOnm Igo k tltyMlhe mommed crtoewue thatno maternal is endorsed Mlicn might injure empoyeea or damage the crematory prepaM- N human remains ate rMWred In a container which Is not suitable for cmnedon such as commercial or Need cafkek Me commonly will regulre thi remains be Moore into a eulLLble container befoe command Me former. The opening of a expansion the transfer ormmoval M remains vall be conducted befog a witness and will be done In givecy, AIM dgnity and M"a IDENTIFICATON OF DECEASED Name of OeceazN: Charles R.Nbmer Marital st s: 8epaefef Last Known Adtle6. 19 Menm Ave. Glens FaIIS.New York CHUN Place of Death: 19 Manion Ave. Dibble Falls, New YoA 12N1 Sax © M 13F Age: 79 Doe: 08-13-1840 DamnGe 07-2ez020 EalmeW Mot 150 Description mcaeMvcontaitrer in""remains all me delivered, Florence Casket, plywood corrugated cardboard container. PERSON INCONTROL OF U$P ITNIN (Persm(r) In m'dml orM1laposiEm. good ONE or me Movement PR Wn we the designated agent of the Monogamy designatetl in a Will or w ii instrument executed purponf to Public on 4201. M1e" W MonssM9e thatthedepressed exected a wrpen inshumam payment to Publlt Health Law GepIM 4201 ora ahon¢Ia me dwWsibron W his ry her remains antl lNre are Me psson(e)basing Immunity under Public Heanb Law he"Me farm to enforcer aemawn a the rsnama of the deceased. *Mur r unship to the deceaeW Is.. follows: Charles R. Werner DOG 1898 f(Rev. WRO) Page 1 of Authorization for Cremation and Disposition add Imr dnderNarama oche remaiw ere rot chimed wntdn ug aayaauemMon, w ur,.s cmmMay wami mardlpw.mmerwaw in 04wan Wednesdays manner, such as of scattering. CREMATION CONTMNEMRN (T ONE o/the/aVowmi An we to be us N as a container am the ounded remeine has Mm purchased from and is described W follows Me ue un\d\�endand that it the we is ton EMI to Mid me enure command remains,an emotional had container may,Ee used Ron woodry. e MumisnaY mrm d. ln underst@Wgatdnoum Ispurchasedcrouennsepmwded Crematory will playa the cremated rebound in A..awmn a rigid temparery mnbinxW delivery. This Authorization Form was pwitlai at, Claim C. Kwgted was mecutetl at M. S. KillFuwrel Home n.,.,..rrvw xa,. 136 Man 3t 3oWfr Glens Fell, Now YoM IMt d.ewmwxem and is sgnM 4 the lowest director as wMess mils executias. awYrn IAi him a removed a composed cool, of this Autlrommumn Form Tge personp) IMntifled Wow lelaregre whoom (s( in control of disposition,"G by signing this AU odwWn Fond, Nbsgef to tM soCYRCy and complexioned;of Had inbmradon oanhlredln Nl uMofiz mom Fonn and arNlw^daee(s)thisb/rrego�ing. Signed Min day Or JUIY 20 /,� Luolle Warner 337 lahshill arApw Fort lodestar New Yore 13838 WITNESS: CklreC Konoem M_e ;;1Mmdm�m c— , � K CIIeMs R.Wsner rr.uve.y M&I 8W(Rau. (141A)b Page3M3 Authorization for Cremation and Disposition pnbn few Me bawwl NumberP Decimal. 11age sumereargh spouse. 1. Agrcm designated In writing deduarlt b Pubic Heats law Secpan 4201131; 2. The surviving spouse, L. The surmang dumeatic panne[ 3. Any M1wmg child eighteen years of age or or A re penal s. A wrvlmn9 sibling eighown door of age or older: S. A NWMIry appointed guardian L Any wlsenb)suffered yeah of aae or men earned to Mare In the wab and"aiLare cb¢est in rel"mo ip to the dema¢ed: e, A duly MaXorted famous of the estate; 9. A soy Mend or relmve who nag evecutaa a wrMm statement purauge to Fred Health low fac ion 4201(7); 10. AMiet Most officer of a coumy or a Mum;administrator appointed aumwm to the Sung 's Coun Rachel Ad, ta. My Omer person Me w aairg an behalf of the daoased and for has comomel a smash statement papuem is Puab Health Low SW*n42mp). r( - IAU SE a Me knowing) its hereby affirm Mat the may ofine deceesad does had Wnbm a batlary, banery yM,p Calls wcllve implant or ramaarve desire and that any such mataals wage remoerd poor ro Me eaeornon M this AaMaspa Form. Fatlumbremove Zdraw tom rbcmmflon may "all Into m mNo hasm e mry and channelwrsonrat. / nth affirm met lnmrutllms have pcen given to Cbly C, toompka regarding me removal M any peWs ll pmpeM Or Mu MIN afvabe when any pmsonragring Mcw or why goal memW Mime desya wishes to preserve. Pine Omw Cmmatary is not rerypn¢ide brine mmonl of Porgonal gems Had the cmb'IIIIN of ern me remains of ten tleceaga. Pomonal items is in " /Conbalnerieve Me mnaina Mll pa WNrpyad py me tramvtlat prouss end ynn0[be rNNeved afbr cremenon. harmy authorize Pine Yon Cremalary IOnwrfM..i M<remab tiro mmains of me dviceaeed. IIMe1OPnDNaq INN Mreby audience the nomad Named anchor to pmvlM New Model to and sramapm by an albmab mvtM, if commed Mode ry In me opinion of the Nneml dlmebr,and to am end this form N provide the cones name and adds M outs albmah c mmabry. FINAL DI9P0SITION Thepawnadhmira Is remNe the Intel rem M M Me dtteasN from the uematpy is Name Pine vim Cremakry Address 21 Quaker Read Dueen¢ary. New York 199M pmxm, 5&T469<77 The damged remains M d wce off the m¢posa Mw fdloxs, If Me ary mays Me wdwm mind abae does fort Wasp ssmn of the vemabd remains. PIM V,m Cmialpy is eumaxed to give {a¢¢esaion of lo�'�y'wne Ne remainaro M. B. glmer Fusel Hone Orgury wiftw by chosenMe in son Or by mgutma mail. CM1aes R. Mme ryw..wm..mp 1)OS18984(Rear OIRo) Pvpef MJ