Martindale Allen Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745.4476
FUNERAL HOME: I1B rl(MfdL RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: _, 71nIA Fj'7///)tt
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
--. I{14M� kT�MLL
NAME: __ IE_IY.IG CASEB
—
TYPE OF CONTAINER: _ FLU (1e [ l 1a.vi n
PLACE OF pPATXI SZIl4 ${ G{ { &r -�,��"'y�II� LrIR41
ESTIMATED WEIGHT OF REMAINS S CONTAINER (IO
PLACED IN HOLD:
PLACED IN REFRIGERATION: q'36 All
DATE OF CREMATION: _ -7)nl V
TIME STARTED: ). QI Pn TIME COMPLETED:
PLACED IN RETORT: 7,wvq MOVED:
RETORT IN WHICH REMAINS WERE CREMATED:
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 40 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOW, rms CARNATION LOG SHALL BE RETAINED IN •NE PERMANENT FILE OF THE CREMATORY.
Department awte
NEWYORK Division Of MN CFCBIMRI6
STATE OF O Com P
°""" °"'" Cemeteries ew"herilnPwnue
eP .:;Sumirl62]a
Authorization for Cremation and Disposition
This Aurhr arrow Tom must hecomplated antl signed prior W Oeliheary,or remains for 1 crematim.
Dom,,7115,2020 Number'.
Crematory Name:FiAe Vlew C�atary
Mdrps:21 Quaker Road. OLmlrsbury,NY 128M Pete.518-745-4417
CREMATION IS for W"EVERSISL AND FINAL PROCESS.
Cremation Is named out by piecing the nrmalns of the dewaced and Me container boding Me remans Into a vadmik n chamber where
they are SINeabd bIntarea heat and flame. The tow and name will lneinwr and mmume serrehiq e6ap1 bone and n 1,
which are all"will be left after crew ion.
Follmving radiation,Me crematory will take leachable eRurts to remove all of Me smears and o fter material upon Me cremation
chamber, but some minimal dust and residue will likely be left CMmd. The ttemebry Fall separate mcdental and foreign malenal Von
Me remains and Me mudenbl and foreign mamnal till be diapason carts required by law. Tin amMMed remains will ba mechaniralry
advanced into small pieces and placed Imo a designated wn mere um. Cr a" m"in$gemralyempulwn edummno
single fragment is recognizably 86 skeedal has",
OPENING OF THE COWAINER
The chemalcry may only open Me container holding the u"mmatad human remains In Thinned urmmcla i such as W mnfum Ms
iden4ly cl the deceased or to ensure that no natural is enclWed which heightened employment OF damage the IXBmaldy propeM, n
human remains en daii"r Inacondlnar which Is not suitable brcmmaxon such as urMrronlal Or ranal Wb4 the
Mabry will hop in that Me mm ins be moved into a suitable wM roar baron It accept the remains. The coming of
Intel Or the transferor removal of remains will he wnduGW balms aowners and will be dons In privacy win dignify and rssnsct
WENTFCATIDX OF OECE ED
Name W Deuawd:uen WMndaly MadW Stain (3 Vcx ce Qi
Lest Known Pddress;52 Orville Street Glens Falk. NY 12MI
Place of Death U rile Sweet Gam Falls, NY 12801
see. ® M OF ful 00a012411957 Dely M Dei 7114421010 Estimate Ww t110
Gosaiption or csaxaumhtaiMr to which remains will be dellvwed.
Florence Casket Co. cremation container (Plywood wmrgated cardboard)
%R Ox x COWTI OF OSPOsm°"
(Ponon(s) ina =wNswvY n. NYiM ONE anew consulate
I amnWe are the designated agent Of Me de designated in a will OF midan ivtrumenl execued purnerom W Public
Hesim Lew Sechom 4201.
-OR-
gets have no knowledge that the decried evicute l a Deno n instrument punuam to Public Health Law section 42D1 or
will camelning directions for the diSioslfhm of his Or her remains and Idea am Me We n(s)having plenty under Public Health Law
Section 4201 ant have the right b aWhenze cremation o1 Me remains lithe deceased. Myrour ml tiOm IPto the deceased Is as
follows:
Allen Martindale
00i Si duff(Rev. 04na) Page I of 3
Authoriution for Cremation and Disposition
(arisen mmo fM ud annual
Number Oesctlptio¢ A survrvins;s lbq egMeen years of age or Diver
1. A deal EesgnaleE in wrNng usuauenl to Public Heard Lew cumpon 420113)I
2. me surviving aF ,
ad, The removal eomoglc partner,
3. My smovng able common years of age or olden,
<. Asurviving parent
5. Aw ran ng aiming eighteen years of age or Older',
6. A bWully Model gutadial
n My penance)eighteen years of or doer w ifted 0 amend in the e9mte and who added abae¢rn relationship to lM deuNMl
a. A cony appaineed Fill of Me Mtale,
9. Acare inane or relative who has ddwAtwc a wrNen statement payment to Public Hadth Law Beason 421O1:
10. A dared read oMav of a county or a public Ad mutual regarded pursuant to tun Sunni a Doun Procedure Act..
1". Any Mal cen¢en who is aNng on behas of loneoeceaed and two bay executed a wfiaen statement pursuant W Public Ha"
Law Replied Al
Qp9jp(AU THREE o/Me anlownpf
Noe thereby affirm that the army of the dewaad doss Ended WWn a battery, Enllery paW pw/, er wl,redicadive Implant,
musical devils,and that any such mammals were removed prior W me consumer of are AU ONZaWn Farm. Fnlure to remora
Mere Rams polar m ca atlon mry result In mum m me proposal add manager pereonnel.
13�— IAVe affirm thatinumtlions have teen given to Timothy Murphy
rrwanmwrra
regarding the n:maval of any posedi pmpeM or other thing of of wake any person signing RaY a any tamYy mamser MMn
Pine View Cremabry
dewased wishes b presi.
a not reepansibb for Me removal of personal items fmm Me wmeimrwhen Ma remere of ten dew . Pe wl IMma lam In Me
East
Ar with Me remains will be Model by Me aremal praxes and arena tea remeved aRer wmauen.
�(LMe hereby muMoriae Pine View Cremdbry �a
m onmam tle mains a tf a deaesed.
(In=OPTIONAL)
Me hereby mode u Ma named funeral din r m pmlda ter MlWery m and cnmatlon by an alternate
mamry, if deemed necessary In Me opinion of the Named director and to amend age farm to provide the coma name and
address Msuch alWMMO mmatary.
FINALDISPMMION
Tlie anon MM2 mRarve ME mmeted remain M the demanded Rose me uerrelpy Is:
M B. Hilmar Funeral Home
Name
Address: 136 Mein street BWM Gbne Fells. NY 12603 pone: 5187l16
The mounted remains of Memel WR be dlsp 06e Ml(W &
Plow In salmagundi warl at graduate
MG
R for any amend the pusmh named above dam not arks pmnsmn title a ao Wremains,
Pee View CTme Is autl w to give Miami a
M
1M¢mans b M B. Itilmu Fumrzl Haore by Miveoy
m a)
in amonm try rpp¢teeM meP. NIenMMkuWe nw+sw.w+w
COS-1R%f(Rio.04130) Page 2 of 3
Authorization for Cremation and Disposition
himal the rmrowing)
a_ Me understand Ma if the remains are rot aainreo wituin 120 days of cremation,
Mine View Crem+bry may dipuee M Me remain In
nw�an...ro-n
an iminavaEle manner, eudi as byewletng.
GREMGTIOM LONTNNERNRN
(Intl ONE of f re blbvmg)
M um I oe used as a anlainm tareta carmbed entire has been Wrcmmal from
and is canceled!as Mbwa:
IWe understand Mat it Me um is van smell b MN Me ditto nameMd amain, an additional Wit mnb'M maybe dead for dNNery
-0,?-
-!L Mum is not yet purchased. Noe uMneeMtlmt if no use Is WrSeadi wdMenme pros
Pine VI"Gtanabfy wet pew the crosmW Mariana in
rwacesd
a Mid Whitest innWtierM daineery.
The RUMrorlxafbn Form won Provided by Toothy funny was emcudd at
M.B. Kilmer Funeral Home
ro+l
136 Main Sheet,South Glens Falls NY 12803 Vuwv rc++
and is signed by the Amid meson as witness to ie emcutbn.�v�nl
Me have magi a completed entry of she AUMa/Uatlan Fornt.
me paraoni Ian10Md badow Is are Me patients)In Modest me imposition, enter by signing this Attenuation Form,ateagq
W Me accuracy and complexness of to mrornwron contained M we Aufhwlzaaw Form and auMcribi Me kiina.
Siena Me lSM day of July ,2p 20
52 pvltla Sheet, Glans FYI&NY 12001
rumor xm.
WITNESS:
TimoMY MuMY
7 0."'.rvmdj aw..l
1250]
AMn ManhAele
davww�d
G 19961(Rev. 0AR0) Page 3 of