Lucas, Janice E. Pine View Cemetery & Crematorium
Quaker Road
Queensburyl NY 12804
(518) 745-4477 or (518) 745.4476
FUNERAL XOMl I _ RETURN TIME: Fbrlee
DATE & TIME REMAINS ARRIVED AT CREMATORY: 2
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS: -
�L #
NAME: rM1_IDG ) S I CASE R �
TYPE OF CONTAINER:: /'MMNIJt ""Y 4x9 • O. _ �Q
PLACE OF DEATH: 6IEn5F I1S Ge.nAA// i57.
lT
ESTIMATED WEIGHT OF REMAINS & CONTAINER
PLACED IN HOLD:
PLACED IN REFRIGERATION: _
DATE OF CREMATION: .Lu -J)Ty(2p
TIME STARTED: IO:b 4 TIME COMPLETIHH if:WS At1
PLACED IN RETORT: IOAOLIT_ MOVED:
RETORT A IN WHICH REMAINS WERE CREMATED: SN[R TNT
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.
ark9w.
NEWYOEK DMSIO MMRI s
L�, Division of
STATE OF oranm wt.Pa.a
�°F " " "'" Cemeteries „Wny.W1231.000e
Teri ;�.Ign4wLb 2s
vereemoll
Auttloriution for Cremation and Disposition
Take Aulhodu Form mast M completed and signed qbr to elegant a nomination nemslbn.
Mte 07/20/2020 "under: gS/
cnmMery Nerrat Pine Yew Crematonum
Addres::51 Quaker Road Gueensbury NY 12804 Phone (518)74.5-04'f/
CREl11 TION 15 AN IRREVERSIBLE AND FINAL PROCE55.
Centel an rs limed am by platleg the remains of the decwul and IM overall aided Me rcneinc into a veme4on chamber there
Vrey ere Pcq'emed b imenae agar end Pame. TM Mat eM Nmowlll Irclrnnb eM cauuma evarymlrrp uwpl bone and mNel,
sMkae sell Malwit MNfleastc F hake n.
ddwic CRmMon e Me umelory awl take 2awnede eMne to remm'h all mMremrt aMoMttmil aMorn nd
Foreign
mallon
chamind Wt and
M minimal EvatdMvagn m will likely ae IMMai o The oemic by volt The
i and immune
end*reign thelenal from
Ina tame send MeinGdenlalaMloreien malwialvnoM demanded ofrmpilred ov Inca. i perm omebscam Mmedmnirslry
puMrvtd imant is pieres and plan$ tern a human,
wnlemeror am. cmrWsd nnvlu g•nxalN.n pala.rlaH amp no
single hagrrem le recopnaabN as vaaxul duw.
OPENING OF THE CONTAINER
Tae crematory may only open Me mmeiner holding Me ancrematem human regal IlmHed circumstances, such as to mnfmm tlN
identity of the demased or to annual Mal no malarial is endceed which Might injure employees or damage Me crerrelory pnpedg N
human remains ere delivered In a coaalner watch Is not suMdF ter cremeeon such as channel an hMxl waaN,ere
crannal will require that the remains M moved Into a suMbla container before N section tlw nmular. The opening as
conlm or or the Warner or removal of remains vdll MwMucted before a wMess and wil M Mine In pMeCy, wM thil and nap
OEWnRCAnON OF DECEASED
Name of Deceased: Jenioe E. Lums Ma Steles: WMovretl
Last Fawn Ad ,152 Sharman Ave., C/o Gaining Falls Centel Glens Falls, NY 12W1
Mee a OR,,Glans Fells Centel 152 Sherman Ave, Gueenal NY 12W4
Sex: DM IN Aid: 82 DOB: W/29/1938 pate of DMM: 0l/10/2D20 Esdmae :gun
Decal ' ofn'aMeYmnWMr n Me remains wi M de ll Nvwa].
. 1� cocct,� n c9./2�,bo�
MMOx IN CONTROL OF O SPOBRION
dPBmwg )a mMmr mMmMwjian *nTe 0.4E re Hre aerosol
I wM4e am the designated a tof the dtteaiM designated M a MR or when assessment Sn Wrwem b RaNc
Hein W SwMn Of01.
/ � tM1Ve haw no kWeringe Mal Me tlenaHd selected aw naslrvmNt pursurnl*Publ'C Heath Lew Section 4201 wa
widmmeinirgm nsbrthwasadernahmorher hernial am Me Pownlq having pncnty under Public Heats taw
Sawwa201 Mve Menghlbauomecremnlonofdwr ins WMed ased. *OurmkVonshlpmMsdx igas
love
Janice E Luces
DOS-1898-I(Rev. O4R0f Page 1 of
Authorization for Cremation and Disposition
nrmmdadme mat lmfpwl
Number: 3 onvipsan: Child. T ddf Powell
1. A pemn designated In writing percent b Put Hawley Law Sxadn 4WI(3).
2. tln summon arwse',
b. TM surviving domestic padner',
3. Any summon child Ngnleen years Of age or All
l Acouniers parent
a. A survnn sibling career,yarn 0l May an oaten:
S. A lawfully apPremed annular,
T. Any,perwn(sl eighteen dean 01 age 0r Ostler,rtdtied W aNre in the estate and who issues crimes In confinement In Me derevM;
S. A duty andented fiduciary of the wide;
e. Atlwe blend or relafive area has executed a wrhnn ebdmaM pmuaM W Public HesM Law Seaton 4201p)i
10. Achlef 0acal officer Of emuMy or a public adMniMlor aptdmed document W the Sumgaee's Coud Fractions Ait
100. Any Other mail who is acting an MMH of the cheesed and who has reawted a who atetemeM pverant W Public Hdon
4w fact e001(7).
( AU TH EmNaloyeav g)
7 AN hereby affairs Nnate bWy of"demared dna tribal a bmrry. battery pack, pawercalt nCmacirsimplam.
w M'roecfive im and NM any such mebMawere rammredpvW ate exeoMlWNie AUMorizatlm Fomr. Failuntoremove
s pear to cremation msy to In Nrm n has shamtlay who canal gnonwL
Moe affirm that membranes ht been given W Wendy M. Bulich
rperdin a handed M any Powellprlsan Or Mar Ming of value which any amend Flying hems deny to mando Oltln
red wines m pmse Pine View Crematorium
a lwl nspanYbn forlhe rtmdel r pbeanal dame M1Om Na MMaiMrp M1Om Na MmeW mMe tlaCeac¢d. Panorul Inns lest In the
wNr the nmfina will esamnoyw bytm nradr.uan mae.a VAndiew
Crem beratorium
ntdwea mane nnmfuon.
nm.ey vuNodn Pine Vi We"aw" tgdum
ry..arsoro roan rM remains r theaxaaud.
PTIONALI
IMv hereby warrants the named Wrists[dwcnrb pievlife nr dallvary,to and cnmatlon by an alternate
cromatme. ofdaamad recall in Me opinion of the fungi al Bader. and to amend NM farm to press the cemct name and
atltlnca of such farmers cremanry.
FINAL DISPOSITION
The person suffered to remove the vematm remains Of the abandoned M1omaevemtlory A:
Name:Tracy Powell
Address: 100 Gordan Lane Lot 311, Gansouoon, NY 12331- Plebe 518-B71-1023
Theaemat¢drem sofdaudwalmdiepdaedm=Mr :
rn Retu W familyeae
abreery rmech Mawrwn southeast due cMm pmmeslm mNeaepthbd comaas,
Pine View Crematorium a w.ehmnd W was poaxuron of
m..owria
y mmeinsw Regan Denny Stallard Funeral Home by eel'nary
"nowaw..rwa
in pvsxt or by regiatecod ref. Janice E. Lucas
WS-te fdo Diane Pti7 Pal 2 no
Authorization for Cremation and Disposition
I
IA a Waalend Nat dre remain are act theme!wMN 120 days Wersh alon.
L
.
Pine View CramalaiNm meyaapmamemruiiam
wwwa m
an able manner, youth nb/moderate
.
LEFYATN]N C ANIEMRN
(BONEMMalament)
An urn to he users as a cuiner W the amended hws been"informed! Regan Denny StanoM Funeral
ma
am a describers as muowa.
INh uMmaW d that Matra um:use.menb held un epre ueme:d remain, an MdIAOnN rga ama'rnr my used far dNivery.
OB.
M um Is Mlyel µrCMSM. WIe urtlemmM nW xn um:pnWeed ar WMiwW gOnEad
Pine Vase Crematorium wag paw the Demme mm:uw in
m.m.eu.�.wn
e rlgM Nmporery oanteirn M Mivery.
The AuNwluxen Form was provided W Wendy M. Bulich was ym Id
Ragan Denny StaftoN Funeral Home
53 Quaker Road. Dueanabury, NY 12W4
ends mgnad the the Nneml director as wanness to as diameter � w
IANe have received a wmplebd own OI this AmFO/IaMM From.
The nnonlel idemmed below Islam Mal»nanal m nomra 0 machines,who by add tM1:AUNO "h Fnm,ahead$l
to Use accuracy and compNenne d bad imment"conendd N the Aum*r F ar arMwheplamft e.
elaoedmle 20ih added July 20
Tra Powell
100 Gardon large Lot 311, Gansevoon, NY 12B31-
uses.minearawe answer,
WIINE&f:
Wendy M. Bulich
m..wnwe.,,wwww.m.w r..w w
10441
Janice E. Lucas
D051r99Ilflev.ClllO) Pagi