Trembley, Marion L. Pine View Cemetery & Crematorium
Quaker Road
Queensburyl NY 12804
(518) 745-4477 or (518) 745-4478
FUNERAL HOME: __ MPFL— RETURN TIME:
DATE 8 TIME REMAINS ARRAYED AT CREMATORY: _ __ 7I17I7U Ia'�pF1n
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
yus?,4 01A5AD
NAME: __ MAPPOO LL __
WM � I CASE R �
TYPE OF CONTAINER: l r �`� 4 �pp� /byL SIt I( N44 h
PLACE OF DEATH:
ESTIMATED WEIGHT OF REMAINS B CONTAINER l6p IPA
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION: IF
TIME STARTED: Ag TIME COMPLETED: 33�
PLACED IN RETORT:
RETORT A IN WHICH REMAINS WERE CREMATED:
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 Or THE CREMATORY.
Authorization for Cremation and Disposition °,m°ae,,,, 6
sa
ve. nw.aa sus
spoi e
Mft Au&o a� Ponn must be corrrpielad m Wgnedpd"to dalhml'of remains forcranMtlon.
pa@: Number Q
Crematory Name. Pine View Crematery
Address. Quaker Road Queermbury, New Yak 12004 Phone: 5181945Nr79
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation Is carried out by placing the remains of the deceased and the container holding the remains Into a
cremation chamber wherethey,aresubjected to intense heat andflame.The beat and Rama will imneMe apt consume
ewmmng except bans and marsh wNtlr zrc all Mal will be left after am~.
Following cremation, the nemamry will take reasonable efforts to re maw an of the remains a other material lmm the
crematio chambeI, but some mia lose dust and residue will likely be left behind.The crematory will separate Incidental and
foreign materlal from the remains and the'mcidental and foreign material will be disposed of as required by law. The
cremated remains wnl be mechanically pulverised into small pieces and placed into a designated container or urn. LNmated
mains gereNlly are pu wM until no angle Fragment B recognizable As skaklal Yasue
OPENING OF CONTAINER
The crematory may only Open the container holding the on cremated human remains in limited circumstances,such as to
confirm the demity of the deceased or to ensure that no material is enclosed whim might injure employees or damage
crematory property. If human remains are delivered Ina container which N rrm suitable For aanaaon audit Be a ceremonial or
metal casket,Me cremat Fall regWre that Me rtmaim be moved Into a suitable container before It accepts the remains.The
opening of a container or the transfer or removal of remains will be conducted before a witness and will be done in prove",
with dignity and respect.
IDENTIFICATION OF DECEASED
Name of Deceased: M L b( Mantal Status: W
Last Known Address:
Place of Deets: I1�b ,. Me
sae: OM OF Age:Sly 008: 21 Datem D�: -a. roll Eadmated Weight I501bs
Description of caskeVwntainer in which remains will he delivered:
Corrugatind Quilpidard Box with Plywood Starmark Mod l 38808
PERSON IN COWROL OF DISPOSITION
(Personal in control of disposition, Initial ONE of the following)
I am/We are the designated agent of the deceased designated in a will or written instrument executed pursoam to Public
Health law Section 42O1.
-0R-/
SL. /we have no knowledge that the deceased executed a written instrument pursuant to Public Health Law settion 4201 or
II wntaining directions for the dispostion of his or her remains and (Continued net page)
oasuu-il�.autm n...ycwmV sill
I am/we are the persanls) having priority under PuNk Heads bw section 4201 and have the right to authorize Cremation
of the remains of the recessed.My/wr relationship to the covatM is as fellows:
Nuarclmm the list Wow)
Number a_g ariptan: v
A person designated In wving purmlmnl M Public Health law secton 4201 (3),
2 The surviving spouse'.
2a.The surviving domesto parter
0 Any summing child eighteen years of age or older.
C. A surviving parent
& A surviving sibling eighteen years of age or older;
B. A lawfully appointed guardian;
1. Any persons) eighteen years of age or oker erdad to share in Me estate and who Ware commit in
relationship to the deceased,
8. A duly appointed fiduciary attire elate;
8. A dose Mend or relative who has executed a written statement premarital Public Heats law §4201(7);
10. A chief fisml officer of a county or a public administrator appointed pursuant to the Suffogate's Court
Procedure Ad,
10a.Airy other person who k acting on behalf of Me deceased and who has executed a written statement predicts
to Public Human taw§4201 OI.
n",nntAU TaaFcol mefn4omrol
I/We hereby affirm that the Wry of the deceasted does not contain a battery, battery pack, power cell, radoactive
Implant, or radioactive device and that any win materials were removed prior to the exertion of this Authorization Form.
Failure to remove these hems prier to wekwdwm may rosin in harm to theaemarory and nemabry persona 1.
� I I/Wehereby affirm that instructions haw been given O go regardingthe
removal many personal property or other thing of value which any person signing below or any family member of the dedwed
wishes to preserve. Invwvv.) Pine View Crematory is not responsible for removal of personal
¢ems from the container or ham the remains of the dere ud. personal hems last in the container er wits the remains Wit be
derhrchl by the crechahon prottss and armn he retrieved star Cremation.
yet� (um l/We hereby autWdzewmrv.0 P' V' C to rn mte of a the remains
madazimsad.
FINAL DapQkagg0X
The person authorized to revive the cremated remains of Me recorded tom the crematory is.
theme; Bak Pars
Address; I I Ladayetteb Nagar York: 128N Phone'. Mil!)T814303
The crertwted Roan M dasona tl will de d'IspasM al as blicki
Rehm M family to be reached
If far any reason the person named above does not take possessor of Me demand remains.
lawn.M�+mil V' C eta
s authorzad W give possession of Me remains to
psiwdmm:�mmel Baker Funeral Home Iw delivery in person or by registered man.
�"� �Tiemblel�
awa®aa w...wwl ' a I
IMle underetand Nat if me remains are rpl chirriea within 120 days of cremation,
(va�abynemnl PneY Cremalory may dispose of the remains In an Irremovable manner,
such as by evermannp.
CREMATION CONTAINERNRN
mLpxeo)uw/drowny)
An um to be used as a container for Me cremated remains has been purchased from Baker
Fun MI Home and Is described as fdlays.
IAW understand Nat Kthe um is too small to rwb Me entire cremated remains, an addNonal ni container may be used
fordelivem,
OR
, y um has not yet been purchased li understand that W no um Is purchased or otherwise Provided ranamm,
mxi Pine Vow Cremabry will place the cremated remains in a ni temporary
container far delivery.
Thekathorhadnn Form war provided by pa,,caam,r el O IaNx k]a]W
was executed at si rve., r n Baker Funi Agin
suvieraa..ea.a) tafav 57 O Yrk 12B11tl arm a signed by Me funeral director
as witness to its eaecubon.
Irri have received a completed copy of this Authorization From
The persons)itlenlifietl her haw team the peravn(a) in counhpl oldiaWsition, "a by signing this Aulfarrzalan
Form, al(est(s) to the accurecY and completeness of Me hrumnallon ppnteinetl in this Authanzatron form and
auNpnze(s) the foregoing
signed Nls Im*� swot TU i, NI
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(3o .c 9 / � pnn n,rOcd Ny lz ! Cs
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WITNESS: (J(�
A� *mraw».,eaxe,a �.Arp...r.uaa.
Funeral Home
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