Gealt, Daniel R. Pine View Cemetery & Crematorium
Quaker Road
Queensburyl NY 12804
(518) 745.4477 or (518) 745-4476
FUNERAL HOME: P pg_lO _ RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: 7IMITA /I -MD Ary
NAME OF FUNERAL DIRECTOR OR REGRISTEREO RESIDENT DELIVERING REMAINS: -
hI11RIC ♦ CAW(�F
NAME: OMP[ l `' Ir CASE4TZ4
TYPE OF CONTAINER: 11 AI • rl.. (mFyp( �MW E •n�
PLACE OF DEATH: V 1 rypwwp RIP{]
ESTIMATED WEIGHT OF REMAINS & CONTAINER`I IW /�� Ar • I
PLACED IN HOLD:
PLACED IN REFRIGERATION: 1
DATE OF CREMATION: l .L� -TITS ITa
TIME STARTEO: 1�YOAT1 TIME COMPLETED: I
PLACED IN RETORT: _ '] to A_MOVED: �Q'y't) FZed L.l
RETORT# IN WHICH REMAINS WERE CREMATED: AK ^EI11
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SHALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
Authorization for Cremation and Disposition
Anew,W 1=wwwo near
Tbls AutlrwWponF mraruat be cWR~antl egoas door an seemly o/ramalns/or mmargon. rs
Oak: 7 .? a����(] N �� bar
Crematory Name:_`{'/,Utd/[e� tM/}jLj/r?arai. /
seeress: a eteaa., " aS�_Jy�7
CREMATION IS AN IRRElASIV IE AND FINAL PROCESS.
Cremation is cametl out by ptadng Me remains of the deceassl and tlro container holding the remens Into a
orientation chamber where May are subjected to intense beet and fame. The Feat and flame will Incinerate and
eaNume everything except bone and math,which are all that win be,left after cremation.
Following cremation, the crematory will take reasonable egok k remove all of the remains and Wirer material fmm
Me cremation clamber, but some minimal dust and residue will likely her left h rtund. The crematsy will expanse
nedental and foreign material from Me remains and the incidental and foreign ngtenal will be disposed of as
reeuirttl by law. The cremated remans will be mechanically pulverizetl into small pastes and planed into a
designated container or um. Criminal remains generally are pulverved urNl no single kagment is
recognizable as skelle tluue.
OPENING OF CONTAINER
The crematory Pay Doty open the container hoping the uaoemsed human remains in IprAed dmurro ancex. Such
as to confirm Me identity W the deceased or to ensure Mal no material is succeed which might injure employees or
damage crematory properly If human remains am deiv red In a container which k rant suitable for transition
such as a carxnonial orrentalcasket, thecrenni will require thntha remains bemovedlntoasutiabhe
conkirrer belare it expense Me remains. The opening of a container or the transferor renpval of remains will be
wnducled before a witness and will be done in pinery,with dignity and respect.
IOENTIFICATWN DECEASEDOF! � //;�
Name of Desesee_{)RAI i EL
&ERLT Mitts statue: A E�
test Known Adtlress:33/
PlatyW ( p / L
Sea: 51M OF Age:OO DOS: Dse of OeeM: ECIF1Sed N'elght1�
OeeuiMbn/ol[mkel/mnkner In xMk tn s will too delivered! //
�� ZAP&54e C&O1 -ar A9, / NEw fN641{tNJ )
PERSON IN CONTROL OF O SPOSITION
fPoron(s) in count of dis war,, ials' ONE liters lalpwvgl
ant We are the designated agent of ft deeased decigneed in a will orwMen instrument executed
WOOO]^y�lll/mdrfff,�(me.rss/W Public Health law sector 4201,
✓ shave no ancwladgethat Me desseard executed a written instrument Pursuant W Public Hw Law
4 1w llmnkiningdire wsfaMedispailn dW are rremeinsand rirtpw)
OJsu/FL- yt /4eow
po 1. tar ere wa.dpA.we erltds
' I add we are Me persons)having prpay under Public Heatsaa section 4201 slot have he right to euMor¢e
aemationaMe rerrnhu ama lece.m. ryroaraljdorahlPmlM plapjeetlMe}olbwj:
(Mart M1an Me4eceuwl ^ G.
Number ' oescripoon: (L�/ T
1. Apaen Panning
spored In wriMg pursuerdm Pubm HeaMlav aeNprr 42M(s);
3.Theaummin copse;
U.Tree aurvlNng danrWlo laser;
1. Airy surviving child eighteen years Gage or older
4. A survlving parent;
& A surviving sibling signal years of age or older
8.A all appointed guardian;
T. Any person(s) eighteen years of age or older entitled to shag in the a"*and who Were closest in
relationship to Me deceased',
8.A duty appointed fiduciary of the estam;
9.A close Mend or relative who has eecutal a w i ten statement Pursuant m Public HeIM tax§4201(7);
10. A chief fiscal officer of a county or a public administrator appointed pursuant m Me Sumgate'a Court
Pmt durs Act
1131a.My abler person who is acEng on behalf Of Me deepened and who has execukd a written speament
pursued In Public Hasidim I.aa§4201(T).
1HFEE a(fre/dlprvlrp)
hereby bMrm that Me body of Me channel does net contjin a watery, be" seek, power cell,
ioacTve implant, or reioective device and that any such handedness were removed prorm Ma asacetion of this
h =a tam Form. Failure m rernnve mau Wi Prior cnnution rosy result in hem m Me crematory and
ro/��a/t/p-/ry eased 1.
We hereby aMrm net instructions have been given mrnvwxmwwni
ardmg Me removal of any Personal pmpeay or odder Ming e��d/d�yj� awTi0 mypgreon epnirg Meow a any MMy
berof Mederaasedwishh bpreerve. rox�xwr�wwi r/.rJEJYiJ (ulll�a xr 2.�H snot
responsible for removal of personal items from Me contaidnr or mxn Mrs n reiru aMe Manuel Personal is
left in Me container or AM Me Andras a0 be tlrboyepl by the arepplied Proms just enrol he Mriward
c ,don. � I�/'T
mAebaaby anurpriae roxmm�� nnJ ,VfOlai.' ( as presents Me
�Mdatm OF Me placement.
EIMLot9POSEEM - ••
Tna peaona el Na Me crenumtl dendm atho laceeeetl Dam tltoaenatwy b:
Hann:_//!!I� 9"" 7:
AdMes: 13it' U�A.d<'tcJ 6.(to5c .tN.fa1�/ PM1ane9d�7f8'37x1'
me/a/�/,sues m.w a, a/eweam all beaWnedaas rollua:
Ifforary seen pawnemxi lee not ww pweeeslon of the cremated Farmers,
Lhh•C.LK" is auManaed In give prceeUn Of the renairvm
Aunvwmm�eaol 6i0(/!./Y� . df by deflveY In pawn w bylisphatereci moil.
O to aw.adds .a dw can2as
n �xpa+rei
WJe uMnamnd tlmf YYn mWna MM cleansed"M 120 days of mamafion,
.uma may diepda mMe mmabs In en IrrarloveHle mlelmnx,
m ea air .
r�Y«aan.nmwry�.
M um to ha wed aemrmtlnsr(orllre crerrwntl remand has been pumYesed f om
and is descnbe0 as folbws:
Unl41Hldalafld Ylaf YNsum bHmanval b hold the entire cremffietl renmins, an adLNanl 68M Wachner nny a
used for dmvary.
u aMYaf GpBn,gyg9HNd. IMburMeropnd had V no um a purchased or oth n se pmviaed
4ir stp soon pumme the mmaiee remains In a new tamporamv
krdelNery.
vmesep aft xj
ff� mod C A< fn : 3'.�5 lgbmWedMYtefi cfiaaor
as wMess to he smmcUtion
IMe have received a oanplahM copy of Ymia Augmfimfbn Fans.
A pafaorda) b (s)tote accuracy and o ploWnoP ofidYan, whoal CQW fq M
Autlnfb mFan, adafb)Pndreaamrecy and complefeneas of the infonnafion paWndb Yda
AutlnrtrAtlpn Fan and auNoebaral lha egoing.
a" dorm L x
ARMINN
*m Wm W hna StRodwo
Okkhmm
mrnwar rSIONMEO
wfmm
sasa.wrsar �' /