Tierney, Thomas J. Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745.4476
FUNERAL HOME: /YI /M C/ _ -._ _ _ RETURN TIME-aL 1
DATE & TIME REMAINS ARRIVED AT CREMATORY:
DDDA
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
NAME: _ JNGS
//�� CASE R _! -JO
TYPE OF CONTAINER: YflP/Cn G4
PLACE OF DEATH:
ESTIMATED WEIGHT OF REMAINS & CONTAINER1Sl��pS
PLACEDIN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION: 7- 79j UTCF
TIME STARTED: IONS,#A TIME COMPLETED: _h/5-
PLACED IN RETORT: MOVED: hI/(o/RETORT A IN WHICH REMAINS WERE CREMATED: Su.2//OLN-p n
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SHALL PERETAINED IN THE PERMANENT FILE OF THE HECREMATORY,
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Authorization for Cremation and Disposition
ThNAUMmintlm Form newt be completetl and signed priorb J lI q� &Crain Intentional
Wta:July 27.2 O Number ti` 76
Cremakry Name: Pine View Crememry
Address,21 Quaker Rwtl Qu WW,New York 12804 pla "_ M8TCuN72
CREMATON M AN IRRE MIBLE AND FINAL PROCESS.
Cremation is tamed net by placing the remains Mthe deceased and the container holding the remains into a Cremation chamber where
they are subjected W all Fein and Rsme. The heft and Rmre we Incimw ant cements qe M except bone and metal,
which are all tlut will be bR other cnmatlon.
Following dematipn Me crematory will rake reasonable effoda to Kmove all MNe remains and other ordeal horn the Cremation
chamber but same minimal dust and residue will likely ba Ion behind The crematory"it eepamm Sol and real materiel from
to remains and Neincidental and foreign material will be disposed ofas rea lM by law ecrematedremainswillbemechenkally
pulvekoed Into small Beres and placed Info a designated mmeineror um. Cmabd maim grlantly am pulverlud until the
single rngmenua recopnbable am alwlwl mue.
OPSNING OF E CONTAINER
The crematory may C My open the wMainer holding Me un.cremated human remains in limited circumstances, mch as to confirm Me
Identity athe deceased or W ensure Mel no materal is enclosed which might injure employees m damage the crematory Woperly. It
hum n remalns an mlivered In a container which is not amlabw for mlon such cue ceremonial or rental cmket,the consul Sell requ Ins that the norm into m maned into a¢uitable corminor bebn it accepts the remains. openinoo a
container or the cral or re mJval of remains will he lrcs¢conducted before a al and will b coM e done In y hill eon reaped.
IDENTIFICATION OF DECEGBED
Name of DeceasW:Tmma¢J. Tierney Mantel Status Maniac
Last"noun AtltlresY u g0onne Ave Sa SW
dh Glens Fails, Near YoM 12
pram of Death Glens Fella Ho¢piW I Park St.Gbm Fall New York IMyl
Sea: 0M OF Age:83 Go, 03-19-1937 Dale 0De,M:07-26-2020 Eedmebawebhl: 150
Oe¢oiwWn of mMe taimr In which remains and be delwered.
Florence Casket, plywood corrugated cardboard container.
(FbraYl(a)7n cmhar or expansion, "A". Cn.blMa blbn$pJ
I amwe an the designated agent W the comma coast abed in awar or wrNen instrument exactas] pursuant W Pudic
Hash taw Section 4201.
-0y�R-s--�
yy lM hwenoknowledge NattMdemandexemtedamhlenIretrumempursuantWPoGic Heam Lax Selion C201Oa
will reasoning Cretlpn¢for the disposers W hie or bar remains and Iran am the personlsj want sei rmy under Public Health Lax
Section 4201 and have the age to supreme cematon of the remains of Isetl¢eel MyrOur relationship to Me(emmIrd le as
fWlew
Thomas J. Tierney
DOS-16084 gi Nap) Pape t of 3
Authorization for Cremation and Disposition
llm�CelueYmwxnal
P rrless undererand NetxNemmamsarenadai xMJn ImmysWchxdl
Fide New cremarey n dispoaea Neremalneln
°smwerr
an manhandled my manner, such, by staftent
CREIMTION CONTAINER RN
fidgkill ONE afford Russell
PTT MumNb uud.IasawWiner WtWaemeMdr ers IlesM puMaeedhwn M. B.KiMar Furenl Hone
and is deserted as felaws'�1`^^"a'^^'
Ii undart hard NM If N¢um he Ioa small W MM Its NNR managed read an addNMtl ngyd Formal may Ee used Msteel
OR
_sun lnrolytlpuNmeeM. VM muxlerMld NMilna um ie Wrdmaredadherwmse pcvMs]
Fine VNw Chiral well pI Me cremated remains In
a dpedlmWrary container for delNery. mr� rear
This Authorization Form was Proceed by cwm C. KWopb wu.womwwv was executed at
M. B. Kilmer Funeral Home
zmaxasaam
IM Main St Sous Glans Falls, New Yak 118N
Man is sglced 4 the funeral director as wMeu to eM executed,
IM1Ne body assumed a fAapIHM mpy a Mee AuWw nFarmIrrfe persons) .
igning
W see wood cy and completeness;of lMPnftmOon confined in I AUNantralesents)In countral at of sposition,and 4 aFees and l wassaflzele tM scrollayee
Signed this IT day of July 30 20
Falrkb Tlemey,
al
0 DefeatDefeatAve Sci Glens Flats, Has York Until
Tw+=,mmmrv... same"
WITNESS:
Gare C.Korupka .L Kon, 040L
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m^ TMmnJ.Twmey
DOS-I&GI.f Frev.Out Peel
Authorization for Cremation and Dfsposfhon
pmertman me hMeero
Number Doomusurn The surviving swum
1.2. Atheld aignatm in ortiig Pursuant to public ha th Law Section 42 113J,
The mry g sprome.
a. TM1a surviving domestic paMer;
]. Any suri child eighteen yeary U age a oWN;
6. Awmving parent,
5. A sumorm SitAing dgMeen years of age or older
S. AlewNlly appointed guakian
T. Anytt on(a)aigdtcen years of age or Oder enuled to more In the estate ant who Ware closest in realimshe le the demabd.
S. A duty appointed temp 0l lM1e esdte;
S. Adose Mend or shows shut has exewtel a writenslatemeM innocent to Public Heats law Stt5on 020IM;
10. AcomifMail cMttr of a county or a public admini54mor appointed µanent to the Surmgeb'a Court Prom unk AE,
the. Any other Person who is acting on behalf ofMe deceased and who has around a wrMen atomism purwanl W Pride Heats
taw Setllw 4201p1.
O Mil AU THREE of the/d usersd
11L IMb hereby infirm Mal 1M bMy of Me deceased does rM certain a betlery, Batley pack, power cell, redioagiw Implam
ormdicamveditiwaMtnmanywchmemdalswaemmovedpdorto Maexemllw Mlhis AUOmfntlon Fmen Fallurebremosa
Mass Items PrlOr W cremation may result In harm W took feernebry and Component p on".
PTT Who¢firm Mat inalrutliaw hew been given Io Claire C Konopb
regarding to removal M a"Pm ll pmpeM or ocher Ming of value which any whom signing below or any buggy member&Me
deomaed wishes to presence. Pyre V'kw Chemistry
is net reapdhaide for the ramowl of puaonal items M1om to containerwlrpnttre remahns of Me tleceax]. PemonallY ale Intl
coo-rr iimrorwithmamruinswnbeds"w WMacmmauonprocureand®nnaWremeV aRercmmeum.
PT-r ulm Maki sudgembe Erne New Crematory
u. m W damage Me mmsim of the dewoaG.
(Mon OPTIONAy
Wn herby aWM1orm Me named funeral durc or to proWtle for delivery to and cnmadon by an tlmmab
mabry,If dwmW necessary In Its opinion of Me Pomnl director,and W amend that form provitleW comer name and
address of*won altemab cmmstory.
FINAL DISPOSITION
The person aulMdxed b remlw Me corseted remains of the dewawd pan the Mitsui is',
No,. Pim View Cmm ory
Aderey_ 21 Ouaker Read Dummbury, New York 128M Phone, 5476Sµ77
TM eremtled remelts of demaxd veil be disposed of as fawws,
awlaswaMe
K for my reason Me parson named ant does rent laps me mm W its uerelm remain¢,
PIm Nm Crmai is ammed to give possession of
Ww
May remains to M. B. Khmer Funeral Home r.Aw bydglvery
in person or by mBlsmmd mail. Thomas J,Tmmy
DOSlS f(Rose 0lddy) m.rw PW2&3