Granger, Hunter Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL NOME:
RETURN TIME:
DATE S TIME REMAINS ARRIVED AT CREMATORY: 7In I IA j'70A_
NAME OF FUNERAL DIRECTOR OR RECHRISTENED RESIDENT DELIVERING REMAINS: -
- FOR: k 4uF0 _
NAME: ... MW(GO /ffi Y[w /� __CASE p
TYPE OF CONTAINER: I_II V Ang, /Mi(RY EO QS4 /FF
PLACE OF DEATH: IAiIi NAF 14Y ,ny(IY� (mJI
ESTIMATED WEIGHT OF REMAINS 6 CONTAINER z" WE /7� fly
PLACED IN HOLD:
PLACED IN REFRIGERATION _ /0 I"
DATE OF CREMATION:
TIME STARTED: Ia'Ysttri TIME COMPLETED: 1p:fr)
PLACED IN RETORT: MOVED: :10
RETORT A IN WHICH REMAINS WERE CREMATED: _ .SIRI/ Ifk{ &K
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SMALL 6E RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
Milo y",stiff
NEWYORK Division of ONWe MUERIe
STATE OIVISION°OFCEMEIERIES
° Cemeteries as miner Avmve
Altmw.NY12231.0001
Twepanen and Grins
snygw
Authorization for Cremation and Disposition
This AuM ads Form must No aompW"and signed pxorto"haviry a rammrm rorwmntal
we Job 16.2020 Number: i39
Crenubry Name'.Pine Vine CremaNay
Addrem:Quaker Road.Queensberry, NY 12604 pecee, 516-1454477
CREM ON M AN IRRUEnIBLE AND FINAL PROCESS.
Carl h[omen oN by Meeting Me remains of Me caressed and me Powder belong Me memory intoa co m iron Chamber where
Ines ere yubjedM 101nlense meal and flame. The had and flame will lmimr and consume owe ing except bone and msW.
which am all that will be aft after cmmstlon.
Fdbwi;vamded,Me crematory Mil fake reasonable eflMs to remove all W Me member and other material map this comment
Chamber, but some minimal dust and re9nue MII likely be left hNiM. The v¢mabry will separate Munenim and foreign mabdal fain
Me remains and the inpnenbl and foreign material MII be disposed of as reguiM by law. The cremated remains MII be mMlannaly
pulvenZetl im0 small Name and planed No a designaled conUmer or um. Cmme dmmMnspsnemlyanpulr du"lno
single Figment Is mongnleable as wall tlseuf.
OPENING OF THE CONTAINER
The crematory may only open the Container holding the umvema@d human remains in limited ciwmslancee, well as W WnNrm Me
Identity of the dommartl or to ensure that no material is showed which might injure temporal or damage Me cremaWry property. N
human remains an delivered In acontainer which Is not suitable far chairman such as ce cAWI or reaMl cash(iM
commonly will require that the remains be moved iota a suitable container will it accepts Me«maim. The opening W a
"Carl or the transfer or removal of remoras von be Conducted More a witness am Mll be dma in privacy, wilM1 dgNry ann respect
IDENTIFICATION OF DECEASED
Name M Deuesed:Hunter Grainger Madrid slaws. named
Last NrUen Address.219 Main St Am 3, HIWm Fete, NY 121131
Pram of beam:11 NaMerim she&. Cams Falb. NY 12MI
Gas: OM OF Age,26 tE.05/06/1994 Delis W Dash:0711MON Eydmatedwayhe-190 230
Grammabn of CBspCUIXntalMr M which remaing still be dHNered.
Minium cremation caskellpine/cardboard (p 69)
PERSON IN CONTRM OF DISPOSITION
(Po (s) In col of dapwn, mi ONE of iM(UIOMl
I annWe am Me Malawi agent W Me nameased desgmted in a MW or woman Imeumenl executed pursuant W Public
Health laws Saclbn<201.
J` OR I
I4P IA4e Move ner the digs Met Citasasedeaeceaawrw,alnmumentpursueving PUNplenty
Unfair taws cnorefe or
See onbintngnimdlmsfor the Msemiedd d cremation of
remainand$O a MeoSed. M)havingpriority ulptr Public ignore few
Malawid$018tltl Nve Ma right b eutlwix cremabm oithe nemain8 One dsaesed. Mylom reltliomM1ipb Me deceased b as
Malawi
Hunter Granger
OOS-1695-f fts". is t Page 1 of
Authorization for Cremation and Disposition
pmsen Mom mensfmla)
Number.2 EuvmpMn. ANNIN accuse
1. A parson designated in wnling pursuant to Pudic HMM Lew 3wtion 400113f
2. The Amusing sompa:
Me. The moving domestic pre er:
3. Any survMrp child Ingrown"am of ape or cider,
L. Awrvi parent
S. A III siding eighteen years Of age Or older)
6. AMall appeal guardian:
T. My moral eghteen years of age a older emitted tosham In Mee stare antl who here dosHtln mammal to the dewaeed:
a. A dub appeared fiduciary M Me estate:
9. A more Rend Or relative who has execute] a arse statement pu real to Public Health Law SetloM2011]y.
10. Achef focal OMgr M a mu my or a puble administrator appointed pursuant to Me Sunni a Land Prcmdure Ach
toe. Any Oalerpe "a is acting on Waif Of the deceased and who has eeemed a valten domment N hand b Public Heal
Iaw Seem 42(1
(nl�g'ALL MREE ath@Oo )
lMehereby affirm that Me tat M Me deceased does net corm n a battery battery park. power cell,Mdical implant,
Orralloedha device and that any each metedak ware removed prior to the masomen of this Authorize4'M Foam. Failumm remove
Maae@items prior to cmmatlon may msuN In harm to the cemetery and cmmalory pars n N an .
xkP Me afinn Met myrazziOre have been gust b Todd G. Kilmer Mavv�
regaMing the removal of any personal h opeM or Other that Nysloe which any person signing helow or any family member of the
deaesed same to preserve, Pine Viau Crem
Ma+wMremp
is net responsible for the removal of ltersome Items M1om the container or from Me remains N Me deceased. Pere@naliw mminthe
cm/lbinsr er wth Me remains will the destroyed by Me cmmaaen prwee amid cannat be MNwd after cremation.
'1 Me hereby,autharue Pine Very GemNay
m.�.drx... to cremate led remains el Me deuvaved.
al OPTIONAL)
INre hereby authorize Me named funeral charter to welds for delivery tc and cmmMlon by an Wrmb
mamry, If deemed necessary 1n Me opinion of the fume red tlir9dm, and to amend Mla bmr In Promme the cowt name and
address of such a6emab crematory.
FINAL DISPOSITION
TM own euMONed he waive Me committed remains of the deceased frcm the uematpy IS
Name:M.B. Kllme Funeral Home, 136 Main Su 30. Glens Falls, NY 12903
Address: 1 M Main M So.Glens Falls,NY 12603 Phone. 518-745-8116
The chemated remains of deeased will he diapered Of as faces:
rebese tofamily
n for any newel Me pl rcon named above does not tans posmsmm of IN amended thowns
Plan View Cram story is auModaed to give possession Of
IM emend b M.B.Klimear paid Henry, rtmwmx.,+ by delivery
menwhissial
In perwin or by registered mNL Nmwm Gmrger
mrewam y
DOSAftoll di MIN Pyl2 of
Authorization for Cremation and Disposition
(�Ma mnpwlr�p)
mor nMsrr and that If ma remalna are mat commove whin tzo days or someone
Fine Vwx cemetery
u d may eiapoae of remains in
an 'removable hams,such as by vice enni
CREMATION CONTNNEBNRN
(itagif ONE ay Ma yw90wirg)
an um M W u$ad as a container for Me cnmaled remains has been purtuaetl from
and u eesonbed as Mlw.a:
Me uneamwmd that rcdn um N on al to hold gas entire uemgW remains, an amnioral WA consumer may W uaM for doivery,
aR-
I�Am am 'a not yet pumhasee. Me seasonal Nm it an um is pertA.Yd or anemia.pmvided
Plre New CnmaMry I place the cremated remains In
smoothness
a red temgaary"Wrier W delivery.
The Auary xwdcm Form miss passage Ey,TWd G. Kilmer was executed as
nmmuw.ra w..i
M.B. Kilmer FuneM Hone
Fxa.swo
1W Mein St Me (grew Food, NY 13303
•and is signed by Nis Ne nn Xe l common as witness to "redeem
INie have renmve t a removed wpy arms;Authoahadnn Ferns.
The pemonis) aentM Wlow islare Me process)In mNOI of dppositen, who by signing this Authorization Form, attests)
to Me economy and mmplaN ess of the labormNles cortaMed In this Aulhorhallon Form and mammas) the foregoing.
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Assam
Tcdd G.Kilmer
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11879
Hurnm Grerpar
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