Dickson Sr. Donald K. Pine View Cemetery & Crematorium
Quaker Road
Queensburyl NY 12604
(51a) 745-4477 or (516) 745.4476
FUNERAL HOME: _e(HSM _ _. _ _ RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY:
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
906 D4 F
NAME: ,._ LO : ("A) 6P CASqED /Y /m
TYPE OF CONTAINER: _ R4YLw. QyIVfS fjYp� /y UAA,E,�y(Q_�pM1{�YI•
PLACE OF DEATHS --A1_L. toj
ESTIMATED WEIGHT OF REMAINS & CONTAINER ILC )M
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION: linl 'g
TIME STARTED: ILRvarI TIME COMPLETED: lrtSppt
PLACED IN RETORT: R.AJO�I' MOVED: p LgRI /75Pb
RETORT N IN WHICH REMAINS WERE CREMATED:
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN OS HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION w0 SHALL BE RETUNED IN THE PERMANENT FILE OE THE CREMATORY.
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STAIFOF a Orecmmmarta Raaa
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Authorigggtion for Cremation and Disposition
This ANMrmden Form must love complel and signed prior o delivery OI pmalM for mrnatil
Date. July ls.2@0 Number S3v
Cremalwy Nme Piysir Creme mom
M&d 21 pinker flwq Oleenabury, NY 12e04 Pam_ (515)]45447]
CREMATION I9 AN IRREBER ME AND FINAL PR=1g S.
Chemical Is barred W by pletlrg Me remains Athe Nodded and tMwmamx ignore Me remains Imo a mme comonmm!
tMyaresupededtoIntensehestandname. TMheMand0 will Incinmleandcomumeav ingeeuptbansage , W 1,
which am all MM WII M"aMmmaton.
Following IXandson, mecrematory will takeseconable efforts to remove all of the remains and other material horn lM thermal
chamber, but some mimmad dust and tesioue will likely be left named The cresomy all separaM Inudental and foreign materiel horn
Me mmairman fthe inCWni a age I ed intmarshal will d disposM of as reguired by few. IDS uemal¢d remains wiN FemeA' arirelry
Wlgle fra Ime small pieces and INa O into a designated ronteircra ury CRnukd mnelM pBMnlly an puNw4ed unM M
single 120mem X nco0nlvdb M ekNaY10W W.
OPENING OF THE COMAIXER
The crematory may only olives tM container holding Me uwemal human remains in limited cwmstanme such as to midi the
idemit of the de0.Ysed or to ensure Met no material is ordered wNT might inrylaempoy9es or damage the crematory recall. X
human remMM are delivered In a con Blow which X not enlbbX for aerosol Such As remm vial or rental cast Me
treasury"I modules Mat Me remains M moved IMo a suitable comalnen befoul NKcepb Me remains. The opening Ma
container or the Mnhr or rema2l of remains will beumducted before a wereas and fall be done In covert,war dignity and respmfIDENTIFICATION OF .
DECEASED c_
Name of LbwaBed. Donal0 W DiMsm Melly Stour: Mined
tan Xnwm Pddel NPhan Ross Imo IA. P Cg119B NY 128%
Pla®of Oeath.. 29 Allen Rol let 14, P Camera, NY IMP
Sa'. ON DF Age: SO DOB.. W'ivi000 Dote of Duck Di115'g02o Faanebl N'e4h 1.25'
DescnptiM Of CaskN¢nUiMrin or remains will W dtlivereo.
MselmateliaYmMeVmmNacbrer) MC ems Aurora W A eM Ca@MN CrnMMl Combined
X LOMROL OF DISPOSITIIXI
(Gnsmr(a) ttnbNWduWsdNn. show unit a[he nom,wlg)
I seM14e ne iM(ksignated Adam of Me dexazed dMA] in a Will or aware instrument executed pursuant to Public
HN lav Ske dkn 0201hPIR
Me Mv0 be interval Met the discussed BveuMd aorden instrument hurt b Public Xealth Law Serum 4201 or a
wi 11 beginning mrtt4Me for Me dispersion of his a M remains and Ifx2 are Me gRoiv 1 having plenty under Pudic N®M taco
9MiM 4201 and have the right to eutMdre ter a0on of the memi d Me dMa%d. MylOur territorial M Me dRMBM X AS
bllwn'
DWxdi(Ddwan
WS1e9i(Rev. 08115) Page1 of
Authorization for Cremation and Disposition
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Nunder. 2 Oeacnphon' sur ivirg spouse
1. A whim designated In wring pueuarit b PUWk HAM daySaha14 1(3)',
2. The wori sill
]a. The eulWnng donandc pMror',
3. Any fuMVing cold Iranian your of age or do
4. A9androg ourerR
S. Aounding clWn9 e'Glteen yesrs of age Or 0lMr
& Alawrully eppo rated guarman,
T. Myeersovi elghown food of Ne w 0lder madded M share In the a ak and wM li tloewt in rel stlonalll p to the recovered.
B. A day appointed fiduc'Iary M me grate.
9. A done Blend to raleM¢who hawandea a Myth rlateme2 WreuaM to Pool H¢mth taw frodon 4301(7),
10. A chief fiscal oMcer of a county Or a Wnlc Anninlstralor apWlned puBWrd in col 3uncgal¢'B Court Pinde eAN.
1M. My ame want will a And on behalf of Me deww9a ant who No wadi a wMan✓ Moment fureuantb PWlk Hwlm
I.w lemon 4WI lrl.
,dial ALL THREE of no kWOwNpI
/j �IMie Meaty Am trot the body,of Me allowed dial not mrbin a battery, EBMry pad, power call, adviii IWhi
Or adlnmu2 dev'YA ell Met any euU meredalSwee RmO`/ed pborblhe evaNlm 0l Mls AUMOIJvtlon Foml. Pollurtbamova
M«.x.w vrlmro cremanen mar re.an In Wmt ro Ma crenwrory and nmmatwy vm.Mnal.
AM—
1=0acorn that Inrtrud'Wna have teen over m Rcde'l1. C m
om
regwding Me removal of any thaaorel prowllydeAa MIN ofvalue III any warn[^Ngnmg bokey or my family mentor Of the
demand wave;to preawa. Plawnew CMn Min
Ia Ml reewn0�01¢br me amavel of peaonM ltgra hcm the wMBlneroihOm ttwo,
i reW�n9✓M.aPee98ed. Peaoror lbme Min e
donne.or Me mnalm will W nwnerw by Me renewed vrawu and Una W wwyAwn~cam n.
YL&—IM'a herby auMMw Pinenax Lmnalorom
b cmmM Me mmBlne of Me tlacNaan.
FIML MSPO0MN
no pe'tm anuffinit b met May aemalN remaNa OF ne Mwawf M1om tW a anlmr'u:
Name. Robed 1. Donal
AWr008
T Meman Averua OwA, NY Inn Pided,. (519)8618395
TW demand remains Ad U wil Wdh Nm1MI
uMrare rewnn uewaadP remW.bOw awa WitNalw«emnaManlwleealem:W.
Plnevir'LmnMw iaw4a¢M loprvatwwYMlo1
t mmomw Determine Furad Hine,Will MWfrM'
in wuwn or try regblemd mail. DMWE DMk Scr
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D061%BJ IRm. WIN
Authorization for Cremation and Disposition
q.Ii the TweOwe�
aC/_ Z— i unaersnna Nn if Me remalmara Mdamea wall 120 days of uemetim,
Plnewleav Crematorium may,chairman d tan demand;In
mnxuemuep
an lrrNnavaok manner. awn as by Meaning
CREYITIONCONTAINE41fl1NN
amen ONE of me@4owmpt
t An um to Ca used as a comainer btlre o-emabd remains may laden W M rnnm from Demmore Manner Hmmy, K
and is described as/dawn: MZZ7� B Sa..{"-v_— U
INh uMcstand taut is a un a Wo mail to ndd the dense eanhatan earl an a]AEwW NO dmtaeNr may to Lead Or odNmy.
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An an is rest yet Wrtllasal Under understand!Net if W um N WrfhYPd or otlwnfw poked
Panes:Cnmebdum wN pees Ne cremated remalns In
a NO hempwary container Or dd'nwy. o�scwnvn
This Authorization Form was prowNed by NCUd I- CenemCR was executed M
�suvwormxmo
Demmom I=nnea Home. no
T Woman Awenue. Comm. IN I= vuw�nu+m
and is clamed or me Nnerel answer se;wurnss m ft swroul. u
IM1Ne have received a competed espy of Nls AuMoriea son Form.
in Mail at
The he the aoconday untydtnd Conlhad mhys handed the pNluaa of NelnlormWtM demanded in this A�n,why 4 staining this A�M�m Fares uNoamdon Feeta d auNmtrefsl they Tmeaola el
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Siena 1Sh says/ Juy
Downs
19 Asian local.Lot 14, PCNCmroq IN 1m
WITli
doom I. Demmore
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