Fuller, Mary D. Pine View Cemetery & Crematorium
Quaker Road
Queensburyl NY 12804
(518) 745-4477 or (518) 745.4476
FUNERALHOME: _�Qr�$� . RETURN TIME: AI ✓—
DATE B TIME REMAINS ARRIVED AT CREMATORY: _ A2$'7ol0
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT OELIyERINO REMA NS:
NAME: /Ni;�� {1 _ /g/� ��Cg3E S
TYPE OF CONTAINER: //'10.�YRFI.F1. - { C.4'
PLACE OF DEATH: i
ESTIMATED WEIGHT OF REMAINS & CONTAINER_AOQ/h Q
PLACED IN HOLD:
PLACED IN REFRIGERATION: _
DATE OF CREMATION: 7
TIME STARTED: TIMECOMPLETED: /O 3SF
PLACED IN RETORT: O�i) -?✓ P�__MOVED:
RETORT # IN WHICH REMAINS WERE CREMATED: ;Oar^f f ly/y
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE THE wewgr:ON LOG SNqu HE flergwED IN THE PERMANENT FILE OF THE CREMATORY.
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Cemeteries gWwrchalk llook.NY feM
Tribble" IdA4wr(]26
Authorization for Cremation and Disposition
This AufMrhetlon Form must ne complc and minimal prior to ANlwy Or ins farcr Aon.
Dolle'. 074d202) Number tloL
Cremehxy Name: Pmoyw Cralrebnum
Address,. 21 Quaker Road, General W t]BN PKm: (513)]4SMTl
CREMATION IS AN IRREVERSIBLE AND RML PROCESS.
Cremation is carried out by spacing the remains of the deceaaetl and the WNyns 1pMirg the remains Into a Mme NambMrxtlere
lleyaresunlecladminensenearandflame. Tne Mat andflemewll$inn ar wd comulreev log aaupt bone and meM1,
wnlcnareal)tnMMIIle IeRabrcmn on.
Manwmg cremation, Me crematory will sake reasonable enwM1 W rem b e ail of the remains and older material Iran the cremation
chamber, bid some minimal dust and residue will likely ba raft behind. The crematory will aaparaM1 ntid¢mal and foreign material npn
Me remains and IM incidental and foresm malenal will dardiepoead May retuaM Will The uemffiad remains will ce Trademark,
downward into small pieces and placed sake a designated bottom der may CremsiMre ass Seasonally ass pulwrhed until no
single Malawi M recognizable as MNetal roue.
OPENING OF TIE COHTAINFA
The samurai may rely,open Me member hkedied the uhIXem human remain in limited circumstances, womwconfirm Me
human
IN am
delivered
er re Malnoer whicliIMGp¢d suitable
Iryureemployeesordamage orepal"Spft X
named Iry wlm are aethat M maainisriarwmm� Is *suita bMforaent bd it bus Memo ireams UakN,IM
mandatory will danger
angethat Norte ofreaimoved into*suitable a Amway
MIMXecmpb the models with
TMke"nat Me
6nlvmr or fire lanskr or removal of remains will As conducted!ONore a wMeva able Will Ea One In privacy.whd tlignily eM reaeeM.
IDENTIFICATION OF DECEASED
Must of DarPaSM: Mary O Fulls "an Santa: Named
beat Known Address: 28Oak St. Conn. W 12M
Peas MCeaM: Vleskry HCC, 1311amM.9 St,S9rabg95p i Ny 12M
Sek: OM NF Age: TT we. 05123ilm DMedD .. M527231 EOma Wdgir Laro—flk>S
Dynamical ad MNW Mtdnerin wnigl M1nals All be conyined.
hypNmMeMMnWellmanulactura) Mel S Australia W arp CeNGVN CmmaMn Cmsanls
PERSON INCONTROL OF DISPo ITION
(ibnm(s)N cmbo oflfi6msllmn. jIted ONE MMe Mlmvmg)
I amNJe are the caught yJ¢m 0 Me deceased desprlBW in a All an serum iarian¢nt exsNetl percent to PubliC
Health Law E¢Glken 4201.
OR-
V& 1 Are Mvenokn Mge Mat saw dreadaeed Sunni a wren instrument puAuanl to Public Head Law Section 4MI as
will cents rush directions My Me bedroom of his or her Rmeire and IM are the pascnlse M N aigTy a near Public HUM Like
Sstcyn 4201 aide haver the ngM M somehae cremation M to remains M May b 8Bs MVQur Maduunep to Ma dacUwd Is as
follows:
Mary D. Fullar
DOS1583-fiRN. 0i Paget of
Authorisstion for Cremation and Disposition
(mxrtmlm Me uupuow)
NumNr. 2 Surviving spwx
1. APalmer danger"in young punWni Pubac lbaM law 5x0an4MI(3):
2. The survliong spruce'
A. The survlNng eomesto Manor,
e. Arry surviving slum eighteen yeas M age or d1dw
4. Asurnving paini
S. A surrrvNg sidling eghteen years of age or older
G. A wormy appoint¢!guardian
T. Any parasols) mghleen years of age or d!#entNM to share In the estate and mus mare Greaarn machine to Ne deceased,
S. A duly accounted fiduaary of Me Hd
9. Adose mien or move Mr has examined a vmtlan statement pursuant R Pudie Haan law beftn 4201(7).
10. A aef i order of a curry a a pulp ammh wImported Wrauan[tr the Singate'a CWn Prwedure Act
lI An/rtM prior Me is wane on ban of the cheers and wM has YeGAW a money shtrirmnl pureuam lr Pumle H«M
law Seam 42m(7}
y (�I A.fU� THREE MMe Wmmg)
!L(-'/—I haehy affirm Mat Me pay,cone da¢asM duties mMam a Nary, battery park mover ern, ndnamis,Imgao,
or h dloaave Nu12 and that any such matenals ware removed pMltr Me Bxttupery i Antonini Form. Falluam remove
n eXeniapdoracmmaummaymute Incani uecm gandemmebry "mnmi.
"e me am"Mat msOuama have peen Omen to Rdterl 1. LW mm w
regarding Xre ancyal of am panmel proerdy or other thing of value which cry errsai ongoing Nkw or my Rnly mem[er of the
demand wlaMsto proverm Plnenaw Ctemataium
Is sot respenu➢la for the r&noval of pBRMaI items from no mnUlner or sown XN remains a Me d hismai PMasaI 11MIF i In 0a
M monJYlmr a with Xro man ina wiN b l ""4 Me criftnrn procw and canna be retrnved r function a .
*--plilBM neren auMorlx Plr mLrematohum
tocr m Me mnalm of Me Mmaanl.
FIRALMO ffMR
Tha perm whonm to receive May common wants ame d.n.ed from the comment n'.
Name RMen I. censmrre
Anmss, T Shernnst Avenue, CcnMh, No 12022 more (510)05Yei
The amered remains of defenn Mn be dp On
MM:
Rc� 14 A �t— 40 '61 F �
If M any,rezaai Ma PoleM nYMl 6YMxs deals tea bare p 4M WMeaemaW remace
Plreaiex Charwomen uaun wwgrvepx sine
sums"Y"i
Me fracture to m
Nenson Fw Hana. line bycommit,
in pnscn a W re ll met.
any, p raw
COS1W6t(Rw.Mr15) mwuew� Page 2 of
Authorization for Cremation and Disposition
(Initlef the M1NW,tine)
W/ INJe unaermen mal if Me remains are M clamed wall 120 om W essential
PNeview Crematorium
tle�l may dlywse of gas narrowed in
an mmeva0b manner, Sol as by R eMMg, mown
CRE W TION CONFAI NE W URN
(tea ONEdgmamowinpl
�An um to Ca want m a mention M re uem remain has Gem puMaud ham Cmsmore Fall Home Inc
and2deunGmaalalows( , curl— 6 k
IAW urbmaarA Nor it Me um is W"I to and Me mNn aemebd re im,an MdMma Red miniver may;be Men for call
O!F
MMie nMy9 putUmad. Wrb uMnaraid M1ulilmwnisglMUMwolhemaapvAdtl
RnMew Cremalodum wilgexdie vemalN remaire In
a Rid temporary maeiner for daivery. �no�rl
Thi9 AUMorlaatlon Farmwas ylOndad Ey RWAt t O mom Nona wmut� at
auwouwuwnl
pnsmore Funeral Hang, IOC
l shsmai Avenue.Cairen NY 1= n..wxvexsry
and w signed IW and Anal diMor as wiaaess to NeaeoNOnxJe��
Ave have rations a Wmpeal mops of foie ANMrhetlOn Form.
The payments) IseMlfiM bbw Ialem Ne pmeontet in mon"I Wdbpw on.and G'/signing Nb AVUNr nForm,AXYNs)
to Me accurKy add COmplbnu W Me seasonal CMWned In MN AYtllm4etlm Few ang eYMm(/ka/s)Ne fORgoing.
Skmd NN Rah day o1 JAy .ld dg sr ��T+ITi Wiliam H FullerY rr � �
08Oek S1., Connie NY 123]2
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R[MN I. Dinsmore
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10910
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l Mary O. FJW
DOS-1ma l(Rev. Celts) Pegs 3 ot3