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Fleeman, Michael S. Pine View Cemetery & Crematorium Quaker Road Queensburyl NY 12884 (518) 745-4477 or (518) 745-4478 FUNERAL HOME: 6e"'L -- -- - ----.-. .(_f_ RETURN T�IIME: �X . DATE & TIME REMAINS ARRIVED AT CREMATORY: ,_( 7'n 3' Zp2p NAME OF FUNERAL DIRECTOR OR REGRISTEREO RESIDENT DELIVERING REMAINS: --_Jaa__ P1AKK P., sfti___ NAME: Pr ckC - cdly __ - 1 p�� I' —�_C4SE p Gs TYPE OF CONTAINER:/+.ar>Yk .l S f �A.j 5 , l ,t 1 PLACE OF DEATH: �y_CGr—g�1Q.{. ✓^F�gsd�J1¢j ESTIMATED WEIGHT OF REMAINS & CONTAINER-2110 +-LULL PLACED IN HOLD: L PLACED IN REFRIGERATION: _ DATE OF CREMATION: -7-JS-Z zo TIME STARTED: / _ TIME COMPLETED: PLACED IN RETORT: A4 ____MOVED: RETORT Y IN WHICH REMAINS WERE CREMATED: S 12Gr: CA N PS DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED VV MORE THAN 48 HOURS FROM TIME OF ACCEPTED DELIVERY: NOTE: THE CREMATION LOG SHALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATeay. mew hunk mr, ////-����-lllll Oepeamarn a San* EWYORK Division of °""'°g°m` "E" `" ST dv untains twerser OMCRT°"'^ Cemeteries T."maw 01M vast Authorization for Cremation and Disposition This AuMor RXon Form must they completed and signed prior No togetry M remalnsbr CMMM n. Date" 0-T/xq)ppl Number ®Gy Cmme W"Name:Pine view crwmtmam must OUNter Road OueemWrr, NY 12804 Par CREMATION IS AN IRREVERSIOMMD FINAL PROCESS. Cremation is camas out by plaung to remains of tin decimal and the mntalnar bolding tM remains no a moment Oamba May are subjected W intense halt and dame The heal and name will Incinerate and cenwma ewrylhing oxmo hone and metal. which are all Feet to 11 b left alterrntwear. Following mmatbn.the Cremabry mall Lake nasonwas eXmla W remove eN of me remains and Other m N"hen Me uemw1gm chamber, WI ume minimal Oust and residue will likely bit left NMNd. The cremalpy arll6apeoab irvidenUl arm loreem mahmal Arm Ind remains and ma Intichnlal and ferelpn materiel vnll 0e diepmed Of an call by Iew. TheaemMebYe ,a WIIbem on,gOy purrogived l Alefragment'nto s ' oem a a e w and dMplaced flaw a Neueatea Wnte r OF am. Cnmated remains peneNl MOW until ne, l m.u O OF THE ONTAINER craI n may only open me amrejner holding the uncmmelea human remains to nmired circumstances. such as a cvnMn the identity Ol me aeo sed or Warsure that no mater Forecast whim might minas WhOmea Or domlpe the G aWn Pmpe If human remains,are delivered In a container which I not s unable for ore mtlion such AN;ceremonial or r $am"t, the emMoa will require Met he remains be mows Into a suable comorer berore X acupte a mmans. TheopeningofF andmero,me vansferorremova of minimal as mnduWaterse a witness and win be ante In money.' ai2nnyana Mesa O NMFCAMON OF DECMEO M Noma of 0eneaed: ' ma lS' F/' ! - " mow swwv Al M L.atXmwnneerear.�Fmx 1 �1\\ I L C `t Er 12 1 W tent PIa Of Oaelh: 6 s u.Z Lesi SL , Wi giii, Fra'1 IItlj Al Sex: ©M ❑F Age: .fD DOE: IL1va 119a1 Doe of Death EOM. We N: Description of mabgoonteimr'm x lch remains will be"M d �I /fl,gii,eal C lt (S:t abaia6vers- ebaber.a i.✓ PRO L OF O aSPPOSMO (Permnlalmunfm/ rmwenl .�wuewme Wanwntel I amA4F are the designated agent W Me a aBW dulenEW in a wd or wham irehu M avoided parsuant W Public H.YM taw Sacllan 4201. -OR- /We have no smae]pa Min the do69ed executed a sell Irmty Nmwnt W Public HwMh Law Star a but or r6awmrq dimCkns tithe dspoainon of Maas her nerni am No me Me parsonm)hevinp anotn9 under Public HeeIM Law Socllon aMl end have An d]MW enthuses cremation dlee remTv Mthe dare Myrourninimshiptothedewesm Wes tallow. m1c tk S . a. PNEI DOS-0098-f how.Ot Authorization for Cremation and Disposition Qnsee hour ma Nil baton) �hy. \C ^ t " Number: W9Ul n: J `Y 1. Acersoil desynaled in writing pulauem b Pubychil lxw SM'cn 4301131: 1. The survMng ap'uea. 3e. The sunNing domesuc paN9ri 3. Any Swri child eVhl lean stage or older 4. A surviving parent'. S. A surviving sibling eighteen years of age an door) S. A Nearly appointed guar0ian: ]. Any icemen(sl sili years of age or died entitled b share in Me estate alp wM10 idms cei In mWtNmNP la the aerosol S. A duly appdnbd fiducary alto 8tl ; g. A dose trend If relebve was has eaFuted a wdllen ebbmml pursued 0 Pul Heatlh use Season 400117II 10. Achief der dficer d a ill Or a public administmew apWlntad punuem N Me Sulrrgale a(curl Procal m Ad. 10a. My Omer person vapor is mul an behalf of Medereaud add vim Ns execute a vn'mel sbtamml pursuant b Public III funny Section 4xOtIT1- (rdi Au Typi of firs,kgse]ngl Me hereby affirm Mat the body of Me dewsaed does not¢ng is,a briery,batlen pack. Mayor bell radioaNva iudi Or hardware device end that any such MM Wk"re lenrned prpr to me spans of Nle AUMo XSE nForm. F1i N nmwe these items prior is cramtllm may mull In harm to the consul and cremebry personnel. XTE— I le slum Met Instructions mare been given to Merle K. Parish ace regmding the n mmal Of my parsmal popery or assay NTg of pairs whW1 arty Perim signing bi or any Imply,member Of ma Pine Vlewcmm Hum deceased wiNp m preserve. Is not measun9de MNs removal of"I Items four Me combiner or and ma remvm of Ma destroyed Personal items left In Na welter Or wits Me mains MII be destroyed by the spur po el and Prmon be rNda ry"after wmadon. IMY hereby euNotlis Pine Vrew Cremamnum Ia•�rwwl bCnmeb Me nosing of Na dscwatl. (yyV��OYTIONIU Yee hereby aullmis the named Nnml director to provlds ter Mllvary,b and cramadon by an attempts crarmusaft, It dwmed necessary In Me opinion tithe humeral tllncal and to amend this false to provide May mrmt name and address et such aMeman crematory. FINAL O®POSMON The purtsn eulhol@ed m rewm me cremated remains of the deceased M1cm Me m=m Is: Name CeMbn rumored Home, InC ddrm OB. Main Sl, Hpdsm Fees. NY 128M pro ]0a$43 Tftl =OM of dwi�be G9lysed WeeV i x far any mean MeeMason named shame does w[teke poBeesslon of mp mmete0 Ta im, P'na VimcnmalMum Is wMh ra gNe McNeal of Ue remains W Carl FUMnI Wvde. Inc. kaayj piratically p erson or by rWYtsed art 6w+xveMi `. 1 l R 005-iSPGf IRay.Oer 1A on-U Page 2 of Authorization for Cremation and Disposition (daisd the folrommp) Me understand Mat It low remain¢are not mimed rvunin 130 days of cematlon, PM View cl.malnrium may m.pmeaM.mm.in.M an bmMevise manner.such Me by scattering. Pwwecsmml CREMATION COMAINERNPN (Ir=ial ME An As everuirpf An um to be used as a container for they command nm ons Ms been puMlaael M1Om am a deambad as follow¢: IANe umYmbM Met itthe um is Ica bar W Mk ther ways vemtled remeM& an addltlmtl hpk consumer m my Me used her di ivMy. -0R An um is not yet purchased. IAVe understand that If no um is pur"i or othervA.e provided Peon View Cmmmenum w11 pass He amended M1Airu In a bomb temporary container for delivery. I ana�wrl This AuthatriWe Form "a pmvMed by Ai N.Pi was eucWed N Cadelon Funeral Name. Inc. rdb>ti.ml Ieuvwx wu m 0 Mein St, Nudam FNIs.NY IM9 India signed by Me luiwrzl director as wilco¢¢to M execution, IArm have mcdved a compli copy of this Ammottrallon Farm. The pemon(sI Identified below Isom Me Pm m(et In control of dlepwMwc who by signing MIs ANMterment Farm.admi bMs ecameryLand complemnsasT000fff Me lnlpmNon wnblwd inside AuM urrim on Form and suMONzs(s)Mawmig,ln3. Signed Mla �_day of NI 2� Tµ�y�� �. Avir VATNPAs' Me*N. Parish 12872 A rndrCihrs DOS-listai Rev. begun Pass 3 a 3