Baker, Bernard Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 11804
(518) 745-4477 Or (518) 745.4476
FUNERAL MOMS: �� _ RETURN TIME:
DATE B TIME REMAINS ARRIVED AT CREMATORY:
NAME OF FUNERAL DIRECT
OR OR REGRISTERED BE DELIVERING REMAINS:
NAME: BfNE1FD BM/� fq // p__CASE<�R �_
TYPE OF CONTAINER: 11� /A IPLij 4ggOq eO'( O(er r* MAd t k Nor
PLACE OF DEATH; INW 6ilh NP44 �/dgu /
ESTIMATED WEIGHT OF REMAINS 8 CONTAINER YIS
PLACED IN NOLIE 2:IBQn
PLACED IN REFRIGERATION:
DATE OF CREMATION: 71Zy Izq TIME STARTED: 1TAP TIME COMPLETED: I' II811 1
PLACED IN RETORT: _ )Jft _MOVED: $ EO/�A}i 9;R�iJ
RETORTS IN WHICH REMAINS WERE CREMATED: AWOL fAez[
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SHAM BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
Authorizotionfor Cremation and Disposition m'saw u:da:ed
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Thla Ar oNaatlon Form mustM conplatetlanasWWplar W dWNalmaterial F cwpa .
Date: '7, ztjW Number 95V
Crematory Name: Pine YKw Crematory
Mariana: Quaker Road, Queensbury, New York 12804 Phone: 5181745-4Q7
CREMATION IS AN IRREVERSIBLE AND FINAL PRI%ESS.
Cremation Is came out by placing the remains of the deceased and the container holding the remains Into a
cremation chamberwherethey are subjected to Intense heat and flame.Me heat and Real evil trademark and consume
everritNng except bone am mNel,which are all that WAR be left after cremation.
Following ne no an on, the crematory wl11 take reasonable efforts to rem uve an of the re me l as a no other mate Par from the
cremation chamber, but same minimal dust and Prince will likely he kR behind The crematory will separate incidental and
foreign era nal from the remains and the incidental and foreign material will be disposed of as required by law. The
d mmeremains will be mechanically pulverized Into small plences,and placed Into a designated container or urn. Cre W
remains generally are Deferral umll no aside fragment Is recognluNe as FkeMal dssw.
OPENING OF CONTAINER
Me crematory may only open the container holding the urn-cremated human remains in limited circumstances, such as to
confirm the identity of the deceased or to ensure that no material is enclosed which might Injure employees or damage
cremanxi property, N human remales are 4f red In a wnGlner which is ARE suitable tar cremation sixth as a ceremonial or
rentals ,the external will require that the rerl be moved into a suitable container before R accepts then s.The
opening of a container or the transfer or removal of remains will be conducted before a across and will be done inpriv rce
with dignity and respect.
IDENTIFICATION OF DECUSED
Name of Deceased: 6crflo- r�)a1li Mantal Status: (Vat ler)
"at known Address: (i 'I Naaj+ol Avc Cp\Cm :!55k i p( 4 /Z801
Place of NAM C)ri�p elinR I
Sex: *M OF Age:9() OOB: 11Ig�ig3p Date of Deem: 2 20 joEaGma[e iAgaight I -f5
Description of askel/rontainer in which remains will be delivered
Ecrulated Cardboard! Box with Phyximod Starmark Model 36808
PERSON IN CONTROL OF DISPOS71ON
(Person(s) in control of disposition, inRial ONE of the following)
I am/We are the designated agent of the deceased designated in a will or written Instrument executed pursuant to Public
Health law section 4201.
-ON-
O8 I/We have ad knowledge that the deceased executed a written instrument pursuant to Public Health row seldom 4201 or
a will comalning directions for the disposition of his or her remains and (Continued All pange)
wswri IR.rural xmxramom, molds
I am/we are the serious) having priority under Public Health Lawsection 4201 and have the right to authorize cremation
of the remains of the deceased. My/our relationship toMe damsel Is as rolbws:
lmsm/mm the he xmwl ((ll
Numl Description'. LJ � { P.
Apersondesignatedinwritingpumwntto Pudic Heatstawa on@Ot (3),
2O. The surviving special
L. The surviving domenic partner,
3. Any surviving child eighteen years of age or older;
4. A surviving Novel
S. A surviving sibling eighteen years of age or older.
S. A lsvfully appointed cadmium,
T. Any pe1Pn(s) eighteen were of age or older outside to share in the estate and who is/are closest in
relationship to Me deceased,
0. A duly appointed fiduciary of Me estate;
9. Aconsidered or relative who has engage ! a merges statement pursuartM Public Health taw§42o1M;
10. A chieffiscal officer of a Party or a public adminlsffator appointed pursuant to the Su bigaM's Court
Procedure Ad;
10a.Any other person who is acing on behalf of Me deceased and who has execNhad a written entertainment pursuant
to Public Health Law§4201p1.
hreth lTHREE fhwhHowM9)
D 13 I/Wehereby affirm that the baud the deceased does not contain a battery, battery pack, power cell,radioactive
implant,or radioactive devire and that any such materials were removed prior to the exeMbn of this Authorization Form.
Failure to remove these Items plar W cremation may result In harm to lire crematory and cremaory personnel.
D$ I/We here ors,affirm that in4ruRions have been given to 9•+nwaI ,wh Cussia 99 life m YI4I00 regardingthe
renewsl of any personal propeM or other thing of value which any peracn signing below or any ismifor member of the deceased
wishes to Preserve. semmavmero Pine View[rematwv isnot responsible far removal of personal
items from the container or Form the remains of the deceal aervanal items left in Me container or with Me Prins watt be
destroyed by the cremation process and cannot be reviewed after cremation.
DBI/We hereby authonu lvrvn� to cremate Meremaim of
the deceaed.
F IAL olsposmox
The person autorites to receive the cremated remains of Me deceased horn Me crematory Is
Name: Baker Funeral Home Personnel
Address: Street. Quegrnsbury Iftedy YOM 12804 Figure: 0181 Ml-9303
The cremable Pertains sessional will be d®posed of u folloxs:
Relum to family to be decided
If for any reassn the person named above does not take potassium Mote cremated remains,
(o.mamry reere) P'neV Cremaory reawhor¢ to give possession of the remonsto
tlweminwiemm:l Baker Funeral Mome by delivery
in person or byregistered mall.
L_]g Y err
oosrsJnlnn.oNp1 Wmxg4vml M1R1ar
(Inlrial@elollowing)
DB IMP understand that if Me remains are not claimed within 120 days of cremation,
rvameimmin) Pine Yew Crematory may dbposeof theremains In an irretrievable manner,
such as by scalMring.
CREMATION CONTAINEFUIRN
[InQiZIONF of tM1ejollowingl
__.An urn M W used as a container for the cremated remains has been pumhetM from Baker
Funeral Home and is described as follows:
INJe understand Mat if Me um is lm small to hold the en&e channeled remains, an addNonal rqd container may be used
For delivery.
.OR.
Q6-An um has not yet been purchased. 11i understand Mat if no urn is purchased or otherwise pronded fawmim
aunt Pine V'ew Crematory will place the crerni remains in a rigid tempo2ry
container for delivery.
This Authorization Form was provided by tri amcwmw) Cassia Rafferty 1114100
was executed at rw+.winw.mw.l Baker Funeral Home
Nww aeuassl ll Lafavede Street Oueenabury New York 12804 aM is egad by the Funerel director
as witness to he executor.
Mines have RceivM a complMed copy of this Authorization Forth.
The persons) iftereffect Wowiamrs the persons) in control oftluposltion. whop by sgning this Authorization
Form, affest(s) to Me accuracy and completeness of she inhmnaflon contained in this Authoriawon Form and
auMor¢e(s) Me loragolm,
Sal ahls 7Q, daya t 2B�Q.
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1�1 .ykc��. c 1 �.\1; tiy IaRot O
WITNESS:
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FunessfirlormaFtem.4i
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rosr�nt�.ourm nww.naemn v4ana