Chamberlain, Raymond R. Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: A$Y1111Mt0 _ _ _ RETURN TIME
DATE 8 TIME REMAINS ARRIVED AT CREMATORY: lily i-ID
NAME OF FUNERAL DIRECTOR OR REGRISTpRED RESIDENT DELIVERING REMAINS: -
AvE jqPgAftg
NAME; M4 2NO CASE E _ P�
TYPE OF CONTAINER: N_ N
PLACE OF DEATH: 4W ys� rypytu{.vl I
ESTIMATED WEIGHT OF REMAINS 8 CONTAINER
PLACED IN HOLD;
PLACED IN REFRIGERATION:
DATE OF CREMATION:
TIME STARTED: "'JOAYI TIME COMPLETED: I4cPt1
PLACED IN RETORT: _ 170ft MOVED: fi Ijl$Qh
RETORT# IN W AbG.INICH REMAINS WERE CREMATED: PAVI(
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY;
NOTE: THE CREMATION LCA SHALL BE RETAINED M THE PERMANENT FILE OF THE CREMATORY.
NEWYORK plVl$IOR Of D•immentaidd,
STATE Of • DNISIOX OF CEMETERIES
OPppkiUXITY. Cemeteries
e I
Tn phow af4walla
Authorization for Cremation and Disposition
Tics Midsummer Form must be cOmPlOtt enosigned morto delivery of remains Mrcremau0n.
Date: 07/142020 Numeer 67L
Cremal Name. Pine VNXV Crete
Address'. 21 Quaker Rd Queansburv, NY 128N Phone
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Diversion or named out by dral Me remains or the deceased and Me mmeinerhOMiig the remains into a q'emedon tliamLerwMre
May are eubiecbd to intense neat and name. The heat and name all InClnerN ands sumo Ovgy lrrg except bone and n 1,
which are ag Mat will be kN doer cmmaeon.
Fmbaing cmma4on,Me crematory will take reasonable efforts to Namove all or the remains aM Chat meledsl from the cramMion
Chamber, but some minimal dust and readue will likely be had behind TleuematorywllleeParatelrWg landbmignmawrialhwn
the remains and the impanel and lmeagn material will ba dispoed Of as repaired by law. The Werra remains will be mechanlwlly
masurrW Imo&mall pings and pIa4W into a designated wnommor or urn. Crymated remains generally am pulwrued un s no
Ingle Inament Is mt ntr W as skelml tissue.
OMINING OF THE COWMNER
The nemeWry may only open the Container holding the unY:mmebd human Retains In limited Gwmlan`ea. such as to Control the
teem y of Me dexased or to ensure that no material is enclosed whi migmmiure empmides or damage Me memory property
human inmates am delivered in a containm which Is not suXabre for cremation such as ceremomal or rental Ceske,the
rotary All uln thistm remains be mead into a domain container beorre haccept the remains. Thempsonao(a
mmainerw Me and"or remi of remains will be Conducted before a harms and will be done in Primary, Own dignity and nowecG
IDENTIFICATION OF DE
Name m wmaxd'. Raymond R. Chamberlain memal stetee DNbmed
Led Mown Mown.. 31 Honcon Ave 6otton Landirg NY 12816
PNm of Deal: Glans Falls Hbspilal, 102 Perk Street Glens Falls, NY 12801
Ser ®M ❑F AEe'. 55 Doe: 11/26/1R patempaM: 0711=020 Emlmeedweillm: 175
Desmpaon Of uakN/mnni,rer in which nmins all be Aminded.
New England Cremation-deluxe container
INS N CONTROL OF DSPOBm
dowelIn MmmlddepJailicn. initml ME am hpowimgl
I wrai are to Ngneed agent of Me tlgmasM designated in a will or when announced a oma rw pudm to Public
Realm Law section 4201,
no MOwledge Met the dereasetl m e dad a written instrument purwant to Public Health Law Section 4201 or e
1r;form db(nsNon of his or her remins and IMg was M pesomsl having Pretty under Putbw Hei Law
Section 4201 and bete the right to authorise cremation idle remains of the dewased. Myl urnlationshiptom MceeeedNn
blbxs:
Raymond R. Chamberlain
DOB Mail(mr; Ni Page 1 a
Authorization for Cremation and Disposition
(/naeR fiwn Its list nebw)
Numbed pesomsem:Suri Child
1. A person devianakEln writing mrsuanl m Pi Nordin Law S¢tion 4211,
2. Tie surviving spwee',
L. Tie Surviving domestic farteri
3. My surviving child egMeen"am al ergo of mach',
d A Surviving parent.
5. A surviving albllrg egMeen Were M pe or older;
S. Amore®bay Appointed guardian;
1. Any person A)eighteen yeah Of age Or older ended to wave In me mare And!who mare hosed in hent"Wmp to the cautioned,
e. A only mnumtm oduciary M me estate;
a. A case Mend or relative "a has exaouer a when Statemem purmarh m Pmmlc Heats ltw Section 4201(1),
m. A chief bass officer m a county or a pubic Administrator apposed puround m the Mrngatem Court Frmkuro Aq;
has. Any
LiverOthererstwho is ardom on behalf M me commed and cots has exmi a well atett im Pmam toMa Panic lnn
n LL THREE of the blbwMg)
Me Hereby Ad he met the body of Me dcommed does not common a betlery. dairy door, power cell redimNve immam,
or 2dimartme device and that any such Marrsdale were removed promo the execution of this AuM otbn Form. FafluMWmmme
3Me name prim to memtllo m n may mount rm In M m the cmnamry and c m roamry weemmef.
IMIe affirm hat ntruuima have base given m Dayitlxender
r w
mgaming Mere al M any personal property or other thing of value which any person signing flaw or my family menbr&Me
dedoaeed wrshes m preserve. _ Pine View Crandabory
Is not mspoi for Me removal M hormonal items how the conminer or hold the remains of the small Penoneli left In Me
nor or M destroyedre
M MS remains will be destroyed by me cmam process and cannot be retrieved vMrarematlon
awa hereby euthosim Pine Uew �Mmatory
� an measure the remains M me dea .
(Mani OPTIONAL)
Prom Mreby euMo ce the named funeral director At promde for delivery to And cm abon by an Mmmam
matltlme W much If mad necessary
alternate monarchy.a opinion of Me funaral director,and m amend arm Man m provide Me correct name and
FINALOMPOSITION
Tl person Authored 10 revive this memamd mmairo Of Me lceased from Me Churl b:
Name:Alexander-Baker Funeral Home, David Alexander
Address._ 3W9 Mein Street Wernenaburg NY 12885 Phone: (518) 823-2W5
The vgnated owns W dxeased will W diamond Mas mnwa.
Rectum W family
rckr am moon tl wrest named above com not core possession of the crenowel remamS.
Pine View Crematory is authorized m give pmusMwW
mmernrZm
the metal Alexander-Baker Fumral Home by delivery
in peace or by registered red, Raymond R. Chamherlam
Itlef(Rev.Wog) Page
g Paget 03
Authorization for Cremation antl Disposition
( raawly)
Inve understand mel Nine random are not aaimm morn 120 apdnremarion,
Pine Viawm Crematory mrydapme dime remains in
an lrrtNev9eh manrer,area an ly ee rf%, `w'""
qREMAAgNOOKAINEWURN
(I !r ONE d 'a lg"'na
An rmmee reed as a deraainer be me cremated extreme roe been Alexander-Baker Funeral
WrcMxe m
and Is Merced all Social
less undemtlnd the"rM are is too smao to WU the Boo cremand remane, an filar al too weaker may W used for defreary
ae-
_An Me is W yet puMasOO IMh undembind not if no um b WrotasW and foil provided
Pine Ulaw Crerrato will pace the Vemated tarsals in
erancn
e ago temporary r+ winw for debrdry,
mid AdnonZSya Form was prpNded dy David Alexander waseeculed at
AkxaMer-Baker Funeal Home
3009 Main Street Warrensburg NY 12885
and is bared by Orc Mal director as waneu b M newrronre..e
We have RgivM a Completed COPY of has Adhwlaa h"Form.
ma personal l MenOW b lShre Ne penonho i n COdrol Or Me p i4M,who by Sig ni he that AWhOraaaon Fom4 afeado
to the aCanry and ComPMlamas of Me n contained In tab Autlrotlntion Form and autierhe(ai the forepdng.
9gned role 14th days July , 20 2020
Meredith E. Casey p t p (1 A Q
151 New Vermont Road, Bahian 4ndng NY 128f 0
evil
WrraE88:
David Alexander
10039 •�•�� m
Raymond R. Chamberlain
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