Congleton, Sally J. Pine View Cemetery & Crematorium
Quaker Road
Queensbury: NY 12804
(518) 745-4477 or (51 a) 745.4476
rUNERAL HOME: _ gR L�F-p
— RETURN TIME:
DATE 8 TIME REMAINS ARRIVED AT CREMATORY:
NAME OF FUNERAL DIRECTOR OR REGRISTBRED RESIDENT DELIVERING REMAINS
S� 0
NAMM SMA.Y too 6 -110 CASE QZ(
TYPE OF CONTAINER: [ 44 [1 IRA/➢ L S� -- RL� #
PLACE OF DEATH: IID 5/( -, 1 �� / / l�i V �)•. _� n9of
ESTIMATED WEIGHT OF REMAINS B CONTAINER_ [ Ml ul (1
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION: T/S h0
TIME STARTED: 71I6M'1 TIME COMPLETED:
PLACED IN RETORT: ' 1(to MOVED: Q'QO /11 ' gAl/m
RETORTpIN WHICH REMAINS WERE CREMATED: UER jam.LA1K
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY'
NOTE: THE CROMATION LOG SMALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
Authorization for Cremation and Dispositionp„,� a,.
Qe Canraa Rem m VyNgpn Rvmmue
Mary.XI'IIDf
IStmpea}M
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TMSAehwhafbn Form muarb complawdmrdarpaa pP be defyaryof mmains /arcfenmalon.
Dam: Number. gZ
Crematory Name:_ Pine V1ew Crcmal
Address Quaker Road Oue rmsbury, New York 128N Phone: 15101745d4T1
CREIMTION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation is carried old by Placing the remains of the deceased and the container hoping the remains into a
cremation chamber wherethn,are subjected to intense have and flame.The hql and flame will iMineraw Me
consume everyming mapt bone and mewl,which are all mat will be IM side cremation.
Following cremation, the crematory will take reasonable efforts to remove an of the remains and Other material from
Me cremation chambeL buft some minimal due and residue will Wary be IM behind. The crematory will separate
incidental and foreign material from the remains and the hak ental and foreign maned will be disposed of as
required by mar. The cremated remains will be mechanically pulveraxi into small pieces and placed into a
designated container or um. Cremated remains generally am pulverized until no single fragment is racognrtable
as sludewl real
OPENING OF CONTAINER
The c matory may only claim me wnwiner funding the u mated human remains in limbed ciwmswnces, such
as to confirm the kantlly of the deceased or to ensure ram no material is showed! which might injure employees or
damagecremmorypropeM- Dhumanremaimamdelivereainacontiln lUbnotsubbwforcrematian
such as a ceremonial or re ad cal me crematory will require mat me remainsb moved into a suitable
container before N accepts me remalrs. The opening of a Camainer or me transfer or removal of remains will be
conducted before a witness and will be done in myecy, with dgnity and respect.
IDENTIFICATION OF DECEASED /1 1 1 [[ll
Name of Deceased: PLItM J6 corfailNDAi Named Small;:y�
Lam Known Address: �IOs'r L.Alt gg2ge Ny �ZyQVIS
Pram of Death: Ito S[A.�N l-et wSt la U if NY l7-AUS
Sex: OM F Age:�DOa: 1_1y -19SI Dateor Deam:�GIZo2O Eeimatea v✓egm:l2p
Description of mskeuwnwiner in which remains will be delivered:
Conupawd Card Ward Box with Plywood Swrtnalk Modm A]SBOS
PERSON IN CONTROL OF DISPOSITION
(Pe ain=lCNE o/me Mbwmg)
al live are the designated!tedesignated! again of the deceased designated In a will or versed Instrument executed
p t)Mmnholddspovlion,Public Health Lew section 4201.
IM4have no knowledge the the de ourvid executed a emblem instrument pursuant to Public Healm Lew
section 4201 or a will containing directions for the deposition of his or her camans and (Com mu aeurnyya)
5 r nr.n�p�rarT
vdsnareu lr+e<. tvlp mm.wne�wd rg.l as
I aM we are me pool having priority, under Public Health Lax aedion 4201 and have Me and to aNhove
cremation of Me remains OF Me Members III mladonnhlp to the discrosetl is as follows:
(lnurthom Me lot below) q IL
Number: 01 Descnimaim b� U agj pow- 10"OV W.GI
A person designates in waiting pursuant to Public Health Lax sacmn 4201 (3);
2. The survlving spwso;
2a.The surviving tlameal pander:
3. My surviving child eighteen years of age or older;
a. A surviving parent;
9. A remaining sibling eighteen years of age or oker;
d. A la'alully appointed guardian;
y. Arty peason(s)eighteen yeam of age or older entitled W where in Me estate and two sure closeout in
relationship to the dominated:
S. A duly amounted fiduciary of Me estate;
9. A close Mend or elative who has a cecutetl a wrNen statement pursuant W Public Health Lae §4201(7);
10.A chief fiscal officer of a county or a public administrator appointed Normal to Me Suminale'S Court
procedure Mt:
1(0a. Am Other peMm who is acM1ng on behalf of the deceased mM who has executed a written statement
pursuant W Public Health Law§e201(7).
THREE offhe felowlnp)
!l's'
IM herebyafPo that Mebodyof Mede aseddoesnotwnWinabattery, hatkryrack, powercell,
radioactive implant or retlioac(Xe tlevice and that any such materials were removetl poor to Me eeeculWn of Mis
Authorization Focal. prime W mmova Mw imme prior to common may much in hams Is the cmnabry and
^^yny crematory personnel.
/\T hWa hereby affirm Mal insWctiws have been grven to ecmmemwwmml SWnBalmTftgt 59 regarding
Me removal of any personal property M other Ming of value which any person signing below,or any family member of the
deceased wishes to preserve. ce aev mm,me Pine Vim Cmmmory a not responsible far
removal of personal items from Me container or from Me mmams of the deceased Pem anal hens IM In Me conminer or
vath Me mmalm will lea dwboyW by M commission
e comssion pm be M eeo and cannot deved commission.seer co on.
I ems' Nye hereby monomer fnrmnnymme) P'ne V'aw Crematon fo enmaW Me
mmains of the downward.
FIML DISPosRIOR
The Oman embraced to receive Me cremated remains of the decamed from the cramatory is
Home: Haver Funeral Home Personnel
Attune; 11 LarlawatheStreet. Queen alsiPhone: f T81b30]
The cremated remains of deceased corn be disposal of as follows:
Realm to bandy to be decided
If far my meson the person named above does not Mke possesses of Me cremated remains,
create? s summand to give possession of Me appeals;to
swam aaernm+al oaks F IHry by delivery in parson or by regkbrad man.
(1(lpl T(1'1 1
oostamAltnr..01110) Ih..nmea In9.xaa
;7, underdmrd Nat if the remains are rm0htleirred wNrin 120 days incineration,
tmvvvr mvs) pine Yew Cremato may(badness of Me members in an inehievsOk reamer.
anti as by scattering.
CREMATION CONTAINERIIIRN
/Im1iel rJNE dare fdrowerq)
An um to be used as a contain for Me commonest remains has been purchanetl from
Baker Funeral Home And is disclo ed as folkxva:
Wya undemlaltl Met RMe um at too matlfo boat Me mMe wemetetl ramairw, an additionalFind container may he useb
for delivery.
-OR-
An um has not yet been pumiu sed. IMre understand Mat if no urn is pumhased or otherwise provi(ep
roamawra.arer P C wiit pace Me assume( remains in a rqd temporary
container for convoy.
The AUOwritatlpr Form urea provHal by a,,mov ,b,
was extended at lvmm ..m,.m Raker Funeral Home
Ammmwaeaw.) 11 La nsW N eM is signed by Me Women dkw
as whines to Fie eearion.
IAHe have received a complete( copy ofMis Authorization Form.
The pennants) Mwdffis l below Islam Me peram(s) in Modest of(lepwmon, who by signing this Authorization
Form, aMeaga)to Me amuracy and Completeness of Me information contained In this Authorization Form and
authodagnl the foregoing.
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