Stevens, Ernest L. Pine View Cemetery & Crematorium
Quaker Road
Queensburyl NV 12804
(518) 745-4477 or (518) 745.4476
FUNERAL HOME: ___ MB(w -- RETURN TIME �Af
DATE & TIME REMAINS ARRIVED AT CREMATORY: _ 21 yib I;W aN.
NAME OF FUNERAL DIRECTOR OR REGRISTEREO RESIDENT DELIVERING REMAINS:
AEUR MA%p
NAME: FA.IIESY yar /' __CASER 1A I
TYPE OF CONTAINER: L�FIIN__rNa // 4IYLt 16I VMDA �- _pq{//gMM(yq
PLACE OF DEATH;
ESTIMATED WEIGHT OF REMAINS & CONTAINER t8O /l
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION:
TIME STARTED: it OG An TIME COMPLETED: IZ•ID Cn
uOn
PLACED IN RETORT: 10:16An MOVED:
RETORT 4IN WHICH REMAINS WERE CREMATED: _ B+4 PQICiC
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOU SHALL BE Rvuxeo IN THE FIRMAMENT FILE OF THE CREMATORY.
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Division of
O°° ". Cemeteries ,m
Tremor, (OrIvAlbe
Authori2ation for Cremation and Disposition
TM.AurM1dRanm Form meal na completed wM slSFnd prior to anvery Mmn.lns Iwcnmauon
Date. July 22, 2020 �r raarnr 86L
Cmmamry team: Da J. (an"torw..
Amoco :i Ia„rbr tgaJ oew b0l W RtOY PhaN:�s� n;-Iron)
CREMA90N IS AN IRREVERMSLE AND FINALPROCESs
Chairman,Is rand out 4y Owing the remains of Me awed and Me c nulrcr MFibq Ne emans vtln a rematipn["ember rdwrB
May wamMWM mimlmae Ma end Dame. no heat and name will incinerate and cwwums waryldy meal bone"mean
which m all that An to lay after migration.
'raaknguMMldl.the venal At lye reasonable won&m romove all of We remark and rafter normal are the common,
GumLa.eN amme mina meet and rescue wnl fire m Ioft behind. The wemeay WTI separate lMdaNl and for*,medal ham
the reasons and the Imadmlal and iwNm mineral Nil be to and of av nal4her, The aBnal or remains will be merMmiuw
aNrisef mmsmml pekes and placed Felon dekynewal conleme or um. Cmmamd moans SamrWly was pulvadmd umn nO
Mnele fragment Is mean....Us u aFaaul tissue.
OPENING OF THE GOINTAMER
The vemalory may Why ouch the coHaler real Na un-vemred human,ummna In IspW nmumsanms.such m to Mum the
idmpn OI lM drnaed or IO Mature Mm ro mrrial Is rwlosad wbicli might inlurc amplM'eas cr amine the uemefury poaRy. If
human romans are delivered m a conYlmrwhich is not network for uematlen mmi we rmmmmial or rental casket,the
mismaterry will require Nat M mmYna be mined into a meltable mnWlmr before It accepts the mmYna no[piing Of
mmrnem Me transfer or rasevrd remain W It mfreedom afore a wTrem and mW be tame m alverm,aM delay and rmpai
IDENTIFICATION OF DECEASED
Name At Powsad.. Ernest L. sieves pMmanda: widowed
"Offered Aaresr 1782 Upper Turnpike Rd. , Whitehall, NY. 12887
PlB of Gaam: Glen, Fell , Hospital r
sex: Opts OF Ape: 91 Dor, 11 /14/1928 Cristobal 07/22/2020 Erbnetem WagM �Wa
DpvlptlM olakFNwManr In which ranains will ma dtlhael. Florence Casket Co.
wood, wood composite base, cardboard top.
PERSON IN CONTROL OF OISPOSTON
(Prsm(S)ManbWydtpJkrTnt,yn�ONE d no AdAww f
I a ate tlw dmynaed aBMl dlhe asemed dp4nG in a our or AmonisWmmMmkd purauam b Public
HolM law Srlbn 4201.
oR-
®11lIN,Iowa no Nmwkdge lout Me darkroom elmnd a wMWnlnsW puneMt to Public anal Law Season 401 we
We canta'mlrg dkrlions for Me dlspositmn Of he or her remains and Owe we W Porm-,$)Nving proney under Pubic Heat law
Sirs 4201 Ad bava Me right to amMae cremation of the remains d the dxa M UwOur relanmehip to the awastl Is as
lei° . Ernest L. Steven
WS-ftl(town 0895) Pepe 1 of
Authorization for Cremation and Disposition
(MSM Fdn Xro NafMMw1
Dowd seen fQ
aumlw _ Wen go
1. Apdem designated M val pursuant b Pldk XMM lax Seefnn 4201
1 The running ignore)
2a The surviving eorneefc pMM:
0. Any,ee ng Chad elgrenveers of ya or oi0er.
a Asonvlog Meant
S. AamNnng diving elgmen yawn of saps or aan:
0. Afa.Nwlr appnlmed gna,amn:
T. My paeeas)eigmeen yMm at ago or dax graef to some In Me"MO anaxlw l5/acaaaolfn MelvnaNpmiMtlNmW',
& A duty appol her send,All of Me Orate:
9. Atlme lrleM or real wM hen macmaf a MnM1n washerm Mail M PUEh Rmllh Weer Sainte AM 1R)
10. AcmN all oN¢v of a munty w a pals;ad"netro aPM1 Wrauam to Me SunoJele'a Go"F ire Ant
10a. Any other penes who Is YK as memo of Me aexasO also rKu hen insulal a tMlten matemam pursuant to Pudc health
Law se;5on 4201
youti1 ALL THREE of Me mamwM9)
®—I Me homey alone Na Me MAY m the dmea does not some a hater.b& pa24 power cal,ramoMiNg amfianl
w n]toetlive Mvt¢eM NM mywT mHeaals wero remdea puiw W Ne mecuiwn MMfs AUNM+eoon Ferm. Fasters mnmow
Iheae terms pow to ommmMn may server N ham A Me cmmalay and uemnory wraoneel.
g `C IMIa Mnm that lnswaXxu herebm gt+n ro Bruce A. Mason 11261
regarding;Me nmrnd of MY Oalaalal mo of(enter Mrtg a1va�+Mo MY heaven fgmy Mdx an e;M for mmea a Me
tl r whe e w.arary to prmerye. Me V
..as eslenmame roMreee the of heavenaeta nfrmm Na enwMa drive Me M.rlemamer Me eaeesam, v.reolaf MAY MY by the
µshear or Min en remain,with W N EY dby Maya ham Wo ss uM ammot mrtmevad arms Cremauan.
(9_45_—NHa hem"lue rue J m
to eramaa the seams a the aemamd.
FIRM Tana Pomposinr Wrecwve N.Oeiuled mrtinatl'e motOeOhan Ne CualtatW fa:
amte.. aruce R. season
Addree: P O Box 2]] Fort Ani KY. 12827 Phone. —639-5252
Tne a.lnwed rmrare a aax9ed w en aap;.ed a s 1ww..:
Return to family.
Xb dry naWeNa pu9on lama]BNre WO rM WupsaOabnattavemaM means.
is ndtvamma••possession d
M d.uvery
m pa.enammg®tam mail.
Ernal L Step"
--
r...+a.w..w
Ppa2a]
W5.i0196d(Rev. MILE
Authorization for Cremation and Disposition
tmwarfaaraunma
3,5 Me understand that rcvrer ons ever that atlmm Wpn tmneraa c'mu0on
psi ryakgeaMraWneln
n..ae..es.n
an onavlsveble manner, such as brshanwllM.
CREMATION COMMNER RN
fkrldf ONE affair rowMnpl
M wn bb then an a concerns Mnn command ramYru INe boar Wrtluaenf om
end 4dam Ted an[Other,
INle umlenWln WI If the um is On an t to Md lic more crescent monsoon. ana]dlvmal No container mry be wed M dNNery.
.OR,,Q.
® , M un Is last W gschol /Me uMmerld that p no an IS p W Or Wherein provided
r L wall dare the OYM191 reasons in
a ego broacher centered,for delivery. W+auea�.W
ThS sumntrauon Form win ashednt by Bruce N. Mason. 12261 wah mmerd at
esm u
Mason,
.al xnm>
and is hgnM Who Nneml dracly M monsm,M IY mention
W/e have mcaayn a mnyJeM ropy M this AulAelvlbn ran,.
The soneni0)identified below bi cep parson(s)In control 0 dlsposidon,who by signing this AWMYaIbn Farm, aft ns)
to six acmra/rya and CCommJplabMea of Ma Interview conwined In Min Adbimfgn Form W auNOMisi the lapel ad.
Signed No ar,of 20 wl0 C �
Jaq�Rsa V�'tII GC IN N.l�.� ,F>,u+ar
40 W Starbuck Ln. , Fort Ann, NY. 12827
opens
wl.�,aay soon
WITNESS:
ra.,..,ev.m-....sBBruce K. Mason
Ernest L. Steven
WSI89&I(Rev. =15) Page 3d3