Kautz, Lorraine Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745--4477 or (518) 745.4476
FUNERAL HOME: "ILFKg _ _ RETURN TIME:
DATE B TIME REMAINS ARRIVED AT CREMATORY:
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
_.. Leael/ee �t NIO
NAME: �lfi E•sy( /�� CASEb 937 _
TYPE OF CONTAINER: F�IWI 4& ( ly fJ'
PLACE OF DEATH: IfIC I'WN'IHGTd`�
ESTIMATED WEIGHT OF REMAINS B CONTAINER_
PLACED IN HOLD: a /yam
PLACED IN REFRIGERATION: II SD /'IFI
DATE OF CREMATION:
TIME STARTED: - � _ TIME COM'IPLETED: J �SPI
PLACED IN RETORT! � jp
___MOVED: /. -*n
RETORT b IN WHICH REMAINS WERE CREMATED: &%ak -VE h T7
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THe CREMATION LOG SHALL RE RETAINEDI M THE PERMANENT FILE OF THE CREMATORY.
NEWYORK Demrm.Mami.
ST.VEOF Division of IMSIONOF(m1WMERIES
°P °" "" Cemeteries
Taa „W474-622k
Authorization for Cremation and Disposition
TNF Added M Form MWt be complaNa and apnea pFlor ro Mx q or remains for CnmabW.
Dow July 14, 202) N"mM'. 937,
Cm "NamB. Piro YexCmnmory
Mdm— 21 Ouaker marld OINeoWrv. NY UNION Pnmw 5167454077
CREMYON IS AN IME ERMBLE AND FINAL MMESS.
Cremedln ins umea and by thicang Me Remains m My aemeee and the M iner Noting the mmalns into a u tian Memberwfixe
they an subjected M intense beat and flame. TM heat and 0me will IndneM end Consume eoeryl l"NNpa Owns And mNe1.
which am all Mat will b NN affair CmmaUm.
Follmnngctemadon, Me oamedy will lake mmna[ effort Rmgg all arm annim and other matenal hmm they Ortmtion
chamber but scene minimal dust and Words or likely by left behind. Lhe uemerorywill eepaAb intidentpl end forego malenalM1wn
the remains antTeInpdanbl and roreien meteal will M diodi olas reaurN by law. Themmg Rena,mwillbemechani®Ily
pulrended am small insider and placed into a dexanalM oonuiw or um. CM=WmnelrgammlyanpuNemD urine
slnefe fmpmelnle Ieaognlssble.u4IMI Dem.
OPENING OF THE CONTAINER
The moment may only Open the commer holding the umcnmatee human Where In limited ammsunoes, ouch as to confirm they,
kleman Remains
e oo tired I I Malmo which
not salwhiMmigMi "onsployee Promm or u lcarypropeM R
humanminime mum
Irndin, Am may"
lontmnMonauraae the ioormMalloeae4 Me
WMabrysumAmre orrmoramelm Ice mo.adI moaeuluble container au Morel) ay don Me nmalr. The Wy and ore
nuirer ornwhanafer orremmel of remxnaxin Ly WMuaea before a wtMw and all [e done m prrvuy, wiln eiemb and reapem.
IDENTIFICATION OF DECEASED
Name of Deceaaee. Mu mne fouK MCMm Searle MamM
Oat W A Mu 32A Bleaker Street,(bwmBe, NY 13075
Pk®of De= Vothaehington Cancer
Sv. Om o nDa. !05 Doe'. 310 19S Damorldral.Innarzozo radmamd Walters 140
regipAan of®skBV Miner in which remains Art be Minimum!
Minimum Cremation Casket, Florence Casket Co. Cardtloard/Pine
PERSON IN COM MOFDSPOS ON
(Pmamilal on about of maP n. Rural GVE of Me M1Lbwug)
I anuMa,are the dumenwad agent m the daddrasad designated in a Mu ar miNm,mou m exel wnnanl t Public
Health Law Sxdon RDi.
OR
QIM§ham no kmM W Mal the teased eaeuNW a weden lnfuument pumant t Public Health use eedlon 42010re
mil sun nngdimMonsbr MadN sA ofhiaorhormmainsaMl am Me Wman(s)MunpnoR uM PuNEt" MLAsk
3iddlum 4201 ant he"to fight b euMome aemeflcn of Re smell of Me mool. Wd ur M UorMp by Me WCneW m as
follows
Lorraine Kautz
DOS.1M f(day W20) Page 1 03
Authorization for Cremation and Disposition
(insurance Mew bemw)
Number 2 Cmirmsen: The aurrane WOuse
1. A prawn EypremO In writing Poo l m Public Xei Lew Bec%m O201d):
]. The survine spouse:
L. The eurNuing domestic Partner
e. Mysurfaced child eiehown were of ape or Older.
S. AsururvNg obang years o/ older
e. AlaMul ndid guarder,
leen apew
T. Any derson((s)f Man"am ofe p pin or older entltledbsham tribe mmm and who lelare danm In ra4tionaM1ip mtlw Mmned'.
he estate
S. Atlde I OfrelaWew0lhas executed a wrplan ethanonl
10. A on let found olfimr of a WUMy or a Public administrator aPoonkd endrtol HealthNl town
owOn Qtatur
10.. My other Huron who m eddied On benalfof the dabe6aB]and who has exerutba a winter thermal PrMdure Ad
taw Seral 4201(H Wnuentm Pubic Health
(IeutiN ALL THREE of cd Wowing)
® rIANA Nreby afar MR the beefy mate decorated does col contain a WftB ,%tent Pads. Power Per necessary Implant
arnd'WC4ve deviceeM lnBl any eucM1 mamdela were remoyd prprmA0 YBN4on of Nis Aulaarhefbn Fonn. Fallummmnme
tlxasllb prorb Omn onmry MSIlt Inhamto NIcnmateryandcmmamryp no .
WQIMb alkm that Instruction haw been III to Stephente A. Gilman evr^m Pant
offering the removal ofcerebraOnal pecgersm SNBr Niepo/valmwhich any"Mon initial Irate y family memdaMNB
Oe¢ased whom 0 WesFre, FmeY Crematory
�wind
is not respOnodefor Ne removal differential pure from the co menerorhpn tlN remain otthe Oemaed. PamdullmmalsalntM
M��wpph�1d�/erorM Partial NNa Partin destroyed by Me cramatlm procue and mnnM W mt ed after cremtlon a .
qIN4 hamby MembrW Piney Crawal
to mama%Ms remalm of the dacx .
(Mew GPTI( NAL)
LW heB suffered Me named mewal chamber m provide for contrary m and cramandon by an alternate
eal If dd necessary In the oplmmm of the Mnan M l direr to
,and amend HIS find remains me Conrad Mee a
m Nma
address of such abmam Osmamry.
FINAL 01BPOBm0111
Me Homeamha¢m mIecerve the n¢mem rednm dma ce®®ae Lcm me v am m.
Name: M B. Kilmer Funeral Home
gyred, U Broadway. FOR SP , NY 128n Phone. 518-767A365
The wanted remains of amB MHWdB a®mlhnm'.
Raleavedm vAXer NeW
If Mr any Mason they person well Mew does me was Hs ion M me aemaMre aim
Pine was,Cnmemry, is auMcnaM to pm Huumna
'newed"an,
Me model No Pill Hiher Feral Home gI,bepNry,
In HeSW or by Mpb teed. O Lomina al
wwwwwased
BOS100Cf(Re+. Salo) Pegg 2 0S
me
Authorization for Cremation and Disposition
((oyme rouowmw
Inva unaamne ham um aill a rema are threshed woman t2oervastonemason,
Pine View Cremabry
AM.wa.�Ml may al¢poaeornarwnair.m
an inemavabb manrnr, w A y ty¢mneMB.
CR YeTOX WKTMNEMRN
( r(ryfr�ONEdlne Mbway
® An um a the man!sm a steeper he to aamatM eases:ea.Dean Wrana.ae Mon, 6 &1e.a„ "t 9 (i
and is mamma as folown (31.. e uK k Al
lMb aMemNM and Kme am N me ameu to nee teener:«:setae remain:. en.eeiuonel Xpa mlmelermav m Ire.:mraeolrery
-0R-
M Um NIKK yel WrWaea. I urder¢WM Hne= lapumhax oroWmipe PIOv d
PIre View CRmaMry
sw✓�X will place the uemetatl remalna In
a reed temporary sneers for mfrtwy
This AuM zi on Form cep prwieaa M Mapnenie A Marine was uecuma At
M.B. peter Funeral Nome
U Mw:way Fort Edward NY 12U8 swasn"mmaW
"wri"i
AM a¢eats:by to Funeral air%er an win all m MypUM agn
INy have re alwad a mmplttea may"A A fundamental Form.
TM mmon(e)ld$MWee mine IMm Na perhol in cereal at Maintains,"a ny Will delay AUNortradon Farm,Barrel
W Me accuracy and comp4eneee at to Information eamalnee In Min Authorization Fomr and euMorleSte)to a prain July
tal MW all an
Weeet KeuK
320 Bill Seep GkMnNm NY IW7S
ArOwn
hum"r"w"Mrs, Asian,
Awnew
wo ave",
StihaNs A German
nmpn..'an, 1r m acaw.
141W
Pepsi
L iM WNS
WSiWby(Rrv.wbe Page 3 of