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Dickinson, Olive Sandy Pine View Cemetery & Crematorium Quaker Road Queensbury, MY 12804 (518) 745-4477 or (518) 745-4476 FUNERAL HOME: _ G7ge RETURN TIME DATES TIME REMAINS ARRIVED AT CREMATORY: Ila I%O (tmgr, NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS: FDNAMIJ }yi NAME: TYPE OF CONTAINER: yd 6A 6SI PLACE OF DEATH: 190 PEAL COy ESTIMATED WEIGHT OF REMAINS S CONTAINER_ ILA /;r PLACED IN HOLD: _ 113T q11 PLACED IN REFRIGIRATION: DATE OF CREMATION: 710-Z o TIME STARTED: q� ._/_ B�_ TIME COMPLETED: 4Q� PLACED IN RETORT; MOVEpD: it, FJiI RETORT N IN WHICH REMAINS WERE CREMATED: 1'T tr 2(c 1S DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN AS HOURS FROM TIME OF ACCEPTED DELIVERY: NOTE: THE CREMATION LOG SHALL BE RETAINEDIN THE PERMANENT FILE OF THE CREMATORY. NWYORK Division ofgT DNISNDN OF CEMETERIES a op PMRTLo..cnmMe2a m..a "'^ Cemeteries 99 wharour,AAl iekglim,618I4N6]26 wsochoul Authorization for Cremation and Disposition This Auscultation Form must As completed and signed prior delivery Mremains Far xccnmat on. Data 0111Y1020 Hamner: IPA Cram Name: Frs,Yimv Cremffiry Auldress, 21 Dwain Rwd,Queenstown, NY 12304 per. (518) 73J477 CREMPTION Is AN IRREVERSIBLE AND FINAL PROCESS. Cameron'A OrmBtl out by placing the remains of me decimal and me mMalner crossed me remain into a cremation alameer Mare they ere s�thermal hear and flame The heal and flame are lntlneraN and consume ewMning except bwy Ado 1, which are all Nal will fle left After cremation. Following aemAon,flee cremaphy will rose norms a eeorot rano ve all of se remains and other material from the champion chamber bizarre minimal dust and reslduevAll Ili A left lbindhire Cement art separate Incidental and forelgn material Mom the wrimms and handful and breion material villas disposed of as repuirl by law. The cremated remains will be meaemiGlly pulver¢l two small pis and plead into a de&goall cur anma um. Cnmabd remains generally an pulvarhl u"l no single mgmmdla recognwble as ssN lflaaua. OPENING OF THE CONTAINER The ae Mq met onlyoften the containm hadmg me un<rematl human remains In limited arcumtiona , such as to aafirm me idaeenry otse det9aeM into ensure via re mabnal laenaowd wnicn mrehf Inure emplcyeenabamage me Uamemry prapMy. N human remaw am delivered Ina copal verwhlcn Ia not flumes,for incomes,such as cernif or Sol eaesel,pu mMabry Mll rewire that Me remains to moved Into a suitable coned.bi itaccept Me remains. The opening of a rviva a trial removal of remains MII de conducted lfwe a wense and will Mature in pawary,with squirts rwgcL IDENTIFICATION OF DECEASED Name of OecAzAz Olive sally Dsk'mson Marital ataWa: wd°'9l Iasi Knwvn AMnss: deal Raub W.flans FIT 12MI Place of Deem vale Raub W.( "m MW 12831 se.: OM ©F Age: 75 DOB. 08/16/1944 oama D..th: 071146HmD ESMMe VsfIOM /ds.f Consul of naMmordamer m Mich remains All lie denverl. Cardboard Box wMlooden Base PERSON IN CONTROL OF DISPOSITION (Poraw(s)In mMW Nsspo,%IMon, enr_nel ONEaIMe Mlawerp) I aml am"designated agent of the deasasl designated In a All or Mlhn'mstmment executed pursuant to Public HAM Lew SaR n 4201. OR IMb M1as,no knowledge that the demaw ems aMnen Instrument suspect b PUMm Heed,Law SMion 4201 ma MI cocain Moment M Me disposition of his or her remains all Was are Me War s)having Poorly under Public Head,Uw Section 0201 all have Me rearm authorize aemafwn eases rail me da'Rasl. Myl rmlaOonsMpbvie Mcaaslbas follows Olive Sandy Dickinson DOS I&A f(Rev OCr2a) Page t of 3 Authorization for Cremation and Disposition nmwebmn are ll# ur xamear s Saturation L')ener zmiaatsi.Nrt 1. A mrson annMN In wntlnB Plural "i XeaM Law Smon AQOl. 1 The Meaning arnaN: U. Tie removal domestic pNner, 3. My moving ctilN annual years of age or older) 4 A surviving parent: S. Asurvmrp siding eghteen weary of no or dtle0 S. A Well apolnle0 g Sunni z. Any person(at Careful years of ape or older andtlee M share in the estate and wholWom Austin in adarma nro to the decesaee. S. A duly apwimed 9dnmary of ten adults: 9. AaNe Mend OMa(we who We executed a weapon statement pursuant m Pul xeaMt 0,Section 4231(7), t0. A OR(Small Opi Of a muMy or a public a0minl¢trator apPointed pursuant In the S Average a Court small AU t0a. Any miser gran one is acting par ndhax of the OewaNd and who has exearter a writen m orment pursuant to Public Health Lew Section 4201D) G ALL TT RREE Oman tndoMng) ^ IANe threby alfinm Met My SAY M Me den dead net contain a batlery,ndMry. pad, pwrer fall, MioeNu2 implant Or nedicactiva deem and MaNnysuch materials form removed prom Meexecuu not this AU or at Fmm. Fallurepremova throe trams minor to cramatlan may may In ham m the cmmmry and aremamry Rmmml. 9lA OmMaNnMcnensnawl npnenm Rolland G. Nwa regarding OR removal of any we al popany or farm thing value who any arson agreed 64ox or any Call temper Of to drfxased wishes M pMserve. PIneY Crematory nmmmnw.0 snot resper ibla oRe RmWy Of Porsonal Ibms from tlm mMalmr Or from the remains came demaso]. Pomm i Name lRin xm Malnrt mwlN the remains will be destroyed bythe Inmates progea and mareal nthvae aMrcromWon. Me arize Pipe be,Cremaory "we"T few m mmab Me Remains of Me W m$Od. f(2tlJ0TI0NAI) Ion ham Affil the "an"Small Amotor to pril film delMry b and rectors by an alternate mamry.N deemed necessary In Ms opmon of the funaNt all tecmr,and to amend Mx norm to prams the comet name and address of sue an alternate CMM2mq. FINALMSPOSITION The Potion auhorized b receive the cremate] remains of Me M[ from the vemffiry a: Name: Compassionate Funeral Care PWral 402 hill Pay SeMya Springs, NY 12W pie, (51S)5S6ABea no mended]remains of eeCeaNd win be dug of as MmM: GarmwM CenMery If for any realm Me peran named move Mass me Wa pssewon of Me va'Nt&I R M. PImV Cm is aMio¢N of Any A>Rmgmn Of control who Me mnminsM CanW'mr FUMN Cam, Inc hy]allrery N Fern or by mpnmmd mil. n�+krx..N OFn Sandy oid'nwn DOS lb f(Rm. MSo) Papa 2of3 Authorization for Cremation and Disposition nwthm IMR wtleM1Wq Tom llthe rcmnms ere Mr caused n1Nm lzo days ornremneon, Pinc New cnmamry M may valued Dime iwn.ms in .n irtepleredle hemmer, such ffiby uedennp. CREtl9T ON COMA NER URN (tea GNE OIme MNw4p1 An um to to used as a consumer tar the crenni native has been purchased than also Is thousand as blla" IMb understand met It me um hlro a+dllb Md the Ili vemabd small an additional Mid conemor man Ad used be d&Nwn, -OR- An June,nets WrNaeed. INYa understand that du um is rumhasa] womMWled physical Pine New Crcnabry rill plats day oremetM remairo'm e rye bmpwery container be harvay ru n,mwr This AUMwtratlon Fame was go Wed by RalGbeing msev6ubeat mvisaivil Composswomme Furenl Cam, Inc 4Q Maple Aw , Swabpa Bpnige, NY 13N# eM Ia$1910 by the Nneral dlredw as enable b us evecubon se IAW have rererved a complAM cyy of cols Aumownral Tom The a z0a nthis Fund'au pal b Sea aral andtmmgnss Ntlre lnbrmapot contained n they AughRSatln Town and aumorkWs WIo polrp. Signed due 15 cal July 3��/ ig Jekcb l✓gslaeazK Z 30 Buuab Lane. Srabga Sprigs, NY 138f6 A I ncIC� � ZC /•t�rx..�Loc%. \ abv. S •ra',.v 5S:.�� \* \'�F, la�p +aw 64_ �{/�.R•�-�2 /,y/y ryp �R $ Rn • rz �-� KaEwPY. , 1. 0 bf WITNESS: Rdlane G. av IY/lA1Y' l wvpNranvnrem, tfrl% / G/yjP L afire san ori� 0 18B&f(Reev.01Y301 l �` 1 pt ( vlck ✓1 /y Ppe3of3