Kussius, Bruce Pine View Cemetery & Crematorium
Quaker Road
Queensbury: NY 12864
(518) 7454477 or (518) 745.4476
FUNERAL HOME: - _ _ _ __ RETURN TIME:
DATE A TIME REMAINS ARRIVED AT CREMATORY: )�Tt 7:,(jfh
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
NAME: _.._ BRYGE K/U�oruS 1 _ J_CAEE R YL7
TYPE OF CONTAINER: _ N GANy
PLACE OF DEATH; ._ 3 (�.l,. e _ ,b�___ - � /c/InI• 11_)Ti�o
ESTIMATED WEIGHT OF REMAINS A CONTAINER_, IF
PLACED IN HOLD:
PLACED IN REFRIGERATION: 1•DO OM
DATE OF CREMATION: 7�1S-- Ap211 "'I
TIME STARTED: — _TIME COMPLETED: �q iiGG _
PLACED IN RETORT: JQ _MOVED:
RETORT pIN WHICH REMAINS WERE CREMATED: PIJfl )O 1 Tr _
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN AD HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SHALL BE RETaxeo IN THE PERMANENT FILE OF THE CREMATORY.
ink SOw
//----1l Oepienem&r
IEWYORK Division of DIVISION OFMETFRBES
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oPPORruxlrr. ibi�m loville
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Cemeteries -0Wl
ne.hIp4M6136
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Authorization for Cremation and Disposition
This Aurnwlaeuen Form must be mmpletea and signed Prior m delivery ar rem im for cmnatibn.
Dare:07/24M20 Number.
crmatory Name: Pine View Crematory
Adtlrem.
Quaker Road OueeneWry. NY lathe
PM1one:
CREMATION Is AN IRREVERSIBLE AND FINAL PROCESS.
CremaSon is arced oN by gated ere remains of the decrease and the wmairwr holding the mmairs into a expressed dumber where
they am subpolar]founder heat and flame. Me heat and Bathe will incir and coume avarytsing except bone and meal.
whits am all Clot will be left after cremation.
Folkvin9 oamaboP the aememry will take reaaenable arms To remove all Drive remains and Oder eaum'al M1cm the vema0.n
Udmber but done minimal dust aM marine will llkdy be left
��v
rapid p.�The anMory utll separate lnddenol and fishom MOl ml from
me remains and meinddenol am foreign material will be dswpgaa Nepal by law. me verreMd remains will be n 8n"IIY
Nursemaid into small pates and perfect into a deagdmef wnmiror mum. CmnaWremaingemmilyampul"e untilm
single fragment is recoamnbk 88 ekdeml uaam.
OPENING OF THE CONTAINER
The reareatiory may only
the essuddher holding the unrcrismater human remons in interior
identify of me decardedOooenwe thin nor m dal is perform when migm injure mpbwa or da s l nag�the trmalory Property If
human mmMna are delivered in a comalner"lch he nor suitable Recommended suer As ceremonial or rental easier,ere
renubry will warder thatthe mmtlns be movatl ii a suitable win inwbMm RaUapm the remains. The hearing oft
mnmin¢r orere tranclmhr remavel W means WII be mntlWeC bebrea sMmu aM veil be tlme In phvery.wM tlignily antl regecL
IDENTIFICATION OF DECEASED
Name of Oecemso Bruce KDss105 Marini Sbtm:
Last most Address 903 County Route 10, Corinth, NV 12822
Plain m Dew'.
Residence
Set: ® M nF Age:G® DOB: 07/10/1952 Date m beam 07,232020 Elimalhe wegm: 190
Description m®skebe ner in Mieh rennums All be delivered.
McDonald basic cremation Container, no interior
0.0 OF MS
NOW is)in comul WOlspwilpn. nr_del ONEd(M1e IdW.wepl
I yNJle are me designated agent of me demazea designated!in a"it or wnnen myth me t executed] pursuant to Public
Heats law S%4on 4201.
K R
rave pxdwNedpeernme desasetlexecutedn wrisenroyal
Writers)saying
pudm Heart taw Sceon 4201 era
lIWmaidiiq aireGdonamrme aiapoddodanb or her remaide Bed Vwe an me peraonp)havingp onunder Publk Health taw
selmn43g1am Headed rgmm amnome Qemedonmthpr rerminamme deterred. Myroermlwon.nip loud detea.ea 1. a.
bll
Bruce Kussius
D0S1818!(Rev. 081151 Page 1 of 3
` Authorization for Cremation and Disposition
bestial Me And
me unchersland Me If Me remains are rot Mariana who 120 days W oenation.
ful
rew may dispose oftne remains In
an inetneveble mama, such as by siaXemp.
CREWVON CONTAINERRIRN
u nn'tlg ONE aft Idbwvgf
An um b In used as a wMairwr for Me diamond remains has been Wrnhasad"in
and Is described as Wool
Me understand that If May um a NO smYl to red this entire vemantl remains,an additional npp Meadow may Oa used M between.
OF /w�s um r' canowis met yet[urUasn. Aft understand their ilno urn is Wrchend w oNervAw Provided!
thery
twnaan,oun
will plan tM aemared nodded In
a rgH lemparery container for delivery.
This A4Maha Fenn was Prenatal by Patricia Miller was wreadeda
raaeawmw.w
&ewer Funeral Home, Inc.
24 ChI5t., Lays Liberal NY 12M
and is signed by Me funeral director day;remess to in sonsonn a
Who Mae modified a ramgeted any MMis Aud oruatlm Fonn.
The perfonts)Idsnr bei IaeR Me pareMtsi in con4q of dbpwltlon,who signing Ole AY odr 40n Form,al 3)
to Me document and complMawss or ere inlarms4an mnbinW In dd AutlleNatiorr Fen and sutlwnzNsi Me foregoing.
Signed this 24 day of , 30 20
>�uQ.. A (Luitw 45a-
.230 i wn1 HILL ao WHITINCIHl ✓7 orlb,
SaSnf.J hi. McCtoSF�� .9�tvdr+� `lK.
,9,Ii3 ri�RoQTZ16 CBkiNrrF��hF/ . i91wa.
Planda M
PaNtla Miller sL�/sfJQ„W
new 1.rr.i ,r rumspTl
12465
Bruce Kual
COS1899.1(Rev. 08115) Pegg 3,03
Authorization for Cremation and Disposition
lhrwnman Me eW brawl
Number; 2ar3 ceaprpfiw: Domestic Penner and son
1. Apeent designated In whang Mrauam to Public H law S&AW 4201(3);
3. The amvntng ¢Wuae:
L. The awviring dmnMic pre r;
5. My the lug cl eighteen years of al or Pharr;
0. Asurvlving parent;
5. A surviving area eighteen yeas U age a older.
s. AlaMulh appoimed auardbn,
T. My Amounted eighteen years N or w doorenl51e1 to share In the eaten and who lLere doped in reasonable W Me dxnaer
a. A duty appdnord fiduciary 0the eatme:
g. A does Mend or reladeve who has unusual a wrlMn statement purwent to Public Health taw dealw 4201M
10. A chief front taken N a wunty or a publicadminldreW appointed pursuant to tM Swroyte'e Coutl Pmredure Act.
10c Any career persm who is sound on behalf of the rectorial and who two mated a wrillm statement Wisuam to Public Heats
Law Setlim Rol pt.
Paley{ALL Inful ofMe(dlowired
— ) M hereby at5maware budy Ofthe doMeed MBe not concern a battery, Mtlery pad, pYMr ttll, red'gaC4v0lmplant
orredpgrve dween and that any Such names wereremoved prior to the common of this Autlwtivtion Finn. Falluretamnove
these Runs prior to cremial may result In harm W Me cremtlary and cremabry pe mi.
� f I Patrida MilNr nvw
AM1@ affirm Metatn inxdana hive been grown
regarding the rengval of any personal propeM or often Ming of value wh'rch any person signing balcw or any famuy member of the
Pine View Crematory
deaaaad worse to prWerve.
.a rim resppnnbleror Me remwaaxrsnnm itemsfmmMe mmmixr`x rpm me rlemain.arms de®a.ea. Penena lama ren In n.
contamer or with Vie remains will be barbel by the moment runway¢and Cannot be R✓Ieved sax Marshll
Pine New Crematory
�lAye hereby somehow
W ammere the remains of the dewaaatl.
FINAL p$POSITION
The narson a dhoneW to rewire Me uemaled remains Name dwayeared IFm tlm symmetry N:
Bremer Fureral Home, Inc,
Nam
26 Chu" Si take Lueeme, NY 12W 51&9 V%H
Addrax. Phone:
The cremmed remains ofdesazM will be disposal W As lowest
Return to family
If he my rre¢m Me game neural above IXp Me calve pwa wWmay vanebd mn ns,
Pine View Crerrocary is terminal W new po Gmnof
Me remains to Brewer Funener Nome, It by dehtery,
xast
In"man or b/rglatxed well
BnICa KUSSius
anti Poo OSr151 ru�u�w Pep2WJ