Sullivan, James Harold Pine View Cemetery & Crematorium
Quaker Road
Queensburyl NY 12804
(518) 745-4477 or (518) 745.4476
FUNERAL HOME: SSP _ _ _ _ RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: _ . _ 7 IJTo lD'FD(In
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
—__ WEFiIl4 BDLSC �(_
NAME: . ..__ _ Eq_�LL11IA t.I /_� CABE/IA __
TYPE OF CONTAINER: R-1{TEE - 6b F yA d &/ EMAtMa/
<1
PLACE OF DEATH: (oy,�ARc—_��t _—�6+ P(MJlllt 1-Y ILUZ
ESTIMATED WEIGHT OF REMAINS & CONTAINER_ I3t )
PLACED IN HOLD: 0'
PLACED IN REFRIGERATION:
DATE OF CREMATION: y"Lyro TIME STARTED: —7 W TIME COMPLETED: 3.iEr P11y1
PLACED IN RETORT: _-lilift__MOVED: , 2 j' r7I3°�h
RETORT A IN WHICH REMAINS WERE CREMATED: _ SW- AmkLAV ,1
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE:TIE CREMATION LOG SHALL OERETAINED IH THE PERMANENT FILE Of NE CREMATORY.
peryN .ymk war,
NEW YORK �iVIS10R 0f °lul°I°"°F N9NF'."^F."
ST AI a eP
OPPORTONIl Cemeteries
3rmP
e.(boaki
wimmirrow,
Authorization for Cremation and Disposition
This AUMwlaauon Form most be compact nth signed briar to gallery of wooalm for Ramada.
pare. O7123I2020 Number
Gemamry Name:igneY Cremat°Num
Amrers.51 Quaker Roadd. Oueensbu NV 12804 Plans: (518) 745-0471
CREMATION K AN WREVEni9a ANO FMi PRO US.
CremNmn is remN M by plating Me remains or the demaeed and the osnlamer MMg the re im my a cemeton chamber where
Mary are subjected to stele neat and name. The nut and r m will McInerney and command eveMhmg except bone and nMY.
Mrker am an MM win be NR after model
Formaing common.Me crematory will take reasonable.isms to remove all of the remains and other melenal them Me cremanm
member, bN game minimal dual and residue MII likery be left behind. The crematory will "PSre I midengl and bMpn mil many
roe remains and tM inaaemal and fom9n msWMl Mil be dipoeW etas reeuiM by law. Tne aemWM slats Hill Ee nreGraniCNly
puNerivtl Into small pieces and plered I=a designatM mntail or um. Uxnelad ramelm wnenlry am pulwread mail m
sink trepment k racagnivble u aka lnaaue.
OPEPAING OF THE CONTAMER
The :mmwMrry may only open Me container coding Me unarem rki human remains In limited circumstances, mch as to wom has
comely long deceal or b ensure mat no matenal is andosed whim might Injure employees or damage the nomal pmWM_ N
human im en delivered In a consulate"job Is not suXable for cremation such" central or mnkl COSM.
mainS
wMelurw thlebanamoraremoval oliremamin will be wkndichi hNae a"needee dwillase don Mampval with dgngla'rl
M reels
OF D CE SED
Name Mcecensee: James Harold Sullivan MehN Sleha: DNoreatl
Ian Nmwn Amira 43 Ridge Street, Apt W6, Glens Falls, W 12801
place W Oil Slate Valley Center For Rehab itnd Nursing , 10421 Slate Route w. Gremilla, NV 128M yk: ®M pF Age 68 DDa 111011ig61 moralizer:Deer: 0]rz1/2020 ENyrlakd wegm0c✓
Desvipgm apmmbwmwnehmwhm mnams winaeNnared.
F NrCw4MROL OF oapOatiNMl
fPaaarrii rM as uncommon anal oNE or me Mppw:npl
arrvWe are Ina megmttd Nml o1Me dBmatad tl0agnalm h e NIII ohwMMr ifSWmeM aseCNM pusmMk PubYc
moral Lae Smdbn 4201.
-0R-
Fare was no knowledge that the morasad execNm a which instrument pumuanto Public Hj isw Sen'wn 4201 or a
will mnWnmg MrMmm for had dleposidm of his or her moral aM Use are Me past hewn.PIMy under Palm Heath law
Section 4201 am care Me rant to aumonm creation Mme mmains of tm deaasm. MylWr relationship W Me tlaceasw k as
Mlws:
James Harold Sullivan
DOS dust f(Rev_01120) paddy I of
Authorhtlon for Cremation and Disp gel
(i riff mthow wow)
Number: 3 Casogrcad. Daughter
t. AW=nhvenaW inwrNnOpw MMWPudic HeeMLaw Se 4201(31',
2. The wrvoug swum:
U. The mMNnp O orl banner;
a. Any surviving Mitl Ingham yeM of age or ode[
A Aawvniig parent,
F. A surrvrviig salt egxNen"am or trip or paper.
G. AMwlullyappointMOutrNun;
T. My personw)Ingrown"am of ape or older ebmd N Were in five areas,and he more Hanson In r Ams pW Me measure,
S. A duty appointed Mucikery d has whiff.
F. A does Meth or relays,rho has executed a wrgen statement WnusM to Pudic Health taw Sweden 0201(7)',
10, A Mkt hsml oPim N a county or a public admhmossr apurded named W Me Surrogate Cowl PostalK
fee. My other perked cope b son can behalf of Me dxeesed and who has exemed a wricen statement punueM W Pudn Heel
Ura Section 42(1(7)
OaddeffALL THREE Were Mar eared
I70, We Mrmy,efirm that the body M Me mutual does per commn a panel battery pack, power call, medical hmptent,
or radm ume dame and that any Such Metal ware Amovad perm to the wooden MMIe Authorization Form, hMte W Mmo/s
haw Rams prior W cremeon my mu" in harm W has creme"and cmm Wpenonml.
MeaMmthathnstmdipnsWet gHnW W daIBBiich
rega W irg ten mmval a per pemmel Pppanr car anw Mop a mkm.nWn per peen agmm peeve'pm.nr lamer mmbm a five
comoud wants to preserve. Pine View Crematorium
is not responsebb for Me removal of assumed home from Ms central'«fidal Me mr ns a Me demaWl pBmpml mmns Nit In Me
c-ormee nene�r or with Me raw My win W destmye by the rnme0m prmus and"More W narrowed after cmmeuen.
�s Ilyh mnaW emxenNe Pine Very Crematorium
W cnnwrs Me mmlm of Mebnem0.
(nnrefp Vi AL)
IMv hereby emxomiiwthe name Wend Member W pror for delivery spend Oematlm rY an ar
Cat n demand necessary in Me opinion other Wmral diroet and to means Mk Wmr W pmwlMMe moment name and
addmu of such aXemRe Merril .
I'll OISP03MN
The peon muromund W moss"the vurest mmehM Were dimmest hoe the oemetmr is:
Name:Singleton Sullivan Roger rura l Home, Wendy M. aulich
Mona Q7 Say Road Qumnsbury, NY 126l pimp: (518)703 69
The tol unmansahammedwill re ascxM N arfdMmx:
Return
to larrily
Ill all teen fie person mire] above ems nut take poae®ian otMe mmM remsds,
Pine View Cremataum Nnafmb]Wgirepos end
temdi W Singleton Sullivan Potter Funeral Home by dell
inmom or by mgsmmd m2 ��� Jams Harold Sullivan
Mo 18911-f(Rev, MID) vu� Page 2 of 3
Authorization for Cremation and Disposition
r�tha rolmwvy
atl�kWa undemmi XW f Xp rarelna an nn WImeE vMMn IN days W Oemallon.
Pine Yew Crematorium mry'dapwadthe remvlmth
anlmbievabk manor,sum an bye®Nang. ✓errs
CREMATION COMAIRERNRH
r�i QVE afore Ewen)
An um to be used as a c unimmer Mine nemead mmalns has been purNesayJfmn
and Is deeuibed as foheas
Me understand thin X W um a Iw sank W Md Me enure narete]mne ns. an eddMcnN npld wmaNr may,be uaM Mdelivery.
�pRu �
1 Mum bnd yet Wanaeed_ Iryie uMenleM NelXroumbpuMeW orolhernee awned
Pine Vim Crematorium wall pleas lM uemNM nmi in
ewmao.rd
a ryq Wnpwary mulamer for dRlrery.
This AmiatrNw Fam was paged by Wendy M. Bull "a euculNn
Singleton Sullivan Potter Furlerel Home
47 Bay Road, Gueembuty, NY 128M
eM is apmd by flay Nm al dllewran W tress b its eveoNw.
Me have revived a command¢py of this Autlwlatlm Form.
The Rename)Ida WInsist some the personbl In wnaal of dispmlXa4 who q sh nhq this Mandaetlar Fame,atrpFl
by eM atturicy and compNY oethen Indonesians awalmd M ma AUMmi[adon Form eM emanations)this foupdry.
8lpmd th4 23N yyaf Juty 2pp 0
Tia Hock
7 Herrimcn
1 Hek OrWa, Glenville, NV 12302-
ienne n.s sessio•
Aduvv
WIFXE88: 1 ^ n
Wendy M. Bulidl •r�'�J T/✓X\
,�..wa.rsmmonrrr.,.r
0041
James HBmld Sullivan
lr+gym
1 0 1898f(Rev. NW) Pap 3 d3