Robinson, Beatrice E. Pine View Cemetery & Crematorium
Quaker Road
Queensburyl NY 12884
(518) 745-4477 Or (518) 745.4476
FUNERAL HOME: JL/
A--- _..—_..__ RETURN TIME: dtan fL
DATE 8 TIME REMAINS ARRIVED AT CREMATORY:
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
NAME: _ n $aN _�CASFB 969 _
TYPE OF CONTAINER: ' lnI[J. - �.,w• �•• � A
PLACE OF DEATH:
ESTIMATED WEIGHT OF REMAINS A CONTAINER_ / 2TS/Lf
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION: 7- 28. pnya/
TIME STARTED: 06PTOM TIME COMPLETE
pD: �O ILAM
PLACED IN RETORT IJGbSA/� _ —_MOVED: /S�Z��OA�//p
RETORT 9 IN WHICH REMAINS WERE CREMATED:
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG $HALL BE RETAINED IN TM[ PERMANENT FILE OF THE CREMATORY.
NEW voRK Division of D°"",� �k
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Authorization for Cremation and Disposition
This Anatomical Form must bs Cprlplstee and signed Prieto MMery&m/mgimftrer Wm.
Dale. Nmner.
crematory es., Pine Vww Crem ry
Ouakarame,OuaenWuy, Nv izeo¢ S13TaSun
Address: more'.
CREMATION IS AN IRR RSIOI AND Fi A PROCESS.
Channel 1>carried oN by Aaong fine remains the remained and Me mnfirl adding;Me remains into a vemation clambawhom
they are whitened W intense Must and flame. The Mat and Rama and [ncinmW and consumer normal extend bone and metal,
which am all but will M bR affair Cnmadon.
Foliating retention the Crematory will take madwable eRCns W remove all of the remains and other material trim the aema4on
Tembar. but some minimal dust and residue will likHy be It armed. The crematory art separate inpeaMal and foreign matenalhom
the remains and IM Mudenlel and Meign malerlal ash be disposed or as roymard by laa. The channel remain all N mMenically
puverized into small Names and placed into a material Yemeni um. Cher d remains generally an pulwmed until no
single themal Is rawgnizabla Me evident bmua.
OPENING OF THE CONTAINER
The normal may only own Me mnlaner holding Me umuemak human remains In limited circumstances, So& as to confirm the
identify of the demanded or to ensure that no material a enclosed hugh might Injure employees or damage the crematory propMy. If
human remains are refusa M Ina container which ie not subai for cremation f rsh U ceremonial or rental mbt,Me
mmetel will"ail Ma1Me remains M moved into a sUiWble eventual MMre do="the remains. Tw ooming Old
COMeindr or the transfer or removal A remains an be one Wed defore a vmneves and will M done In Wivacy, vnln dignify and nespecl.
IDENTIFICATION OF DECEASED
Name Ol Demands Fiji E Pmn" Mantal steals Married
Iael Knower Address. 5fmr00y .1s,Layers.NY nasal
Place of Death: sendq Ha W,same,>pri NY new
Sex'. El IMF Age. 87 Wa', 1111911932 End Of TD42020 Esfimata MgM 26
Desmphm WcaakeV tainwinwiMremmnswillMdelmered.
McDonald basic cremation Cornainer, no interior
PERSON IN COWROLOF MMSn ON
(Persan(sl in cnvaormspwmm�, ini6el oNEama wrowvt9l
e H Section
art Medesigremd agent alMa dexesM dslgletM inawill orwripM InWument erBatW Wreuentlo Publk
CVIIh taw Sedicn/201.
OR
sF� T de Mvan Mr the deposition
Ma tMswd moral
executed and
Meen(pursueMlo Public Heads ll tewaWgn Qa wa
II ant nin9 dire lions a Me do summerof his a on remain>ens ,of are Meemseddemands)( having iaboMunder Public maybe taw
Section 0301 and have Me right to auNorize oemeem mlM1e remainaMMetlecaeeed. MylOur reletioruhip to Me tleuaeed H ee
bll w :
Beab+eE noYmn
00S13�f(Rev. (W15) Page 1 of 3
Authonrahon for Cremation and Disposition
�(�OcOWMe?rwawmm
�}� [We understand that nMe agrees are na aaimeo tense 1W deed Mmmusen.
zpaae` rw Summary
2 mgalepme or Me renalmm
an inrae.tek manner mace as Wacenenamg. �
CRENAT ON CONTAINENU IN
Media ONE i loffiene)
An um to ee ueM as a minsire!for Me udnmee Rmaies has been puMased rmm
andlademcrlaeeasfoma.-
Ave understand that If Me um is mo most ro hold this @man namakd owners.an addloorel deal mntaker may IM usedW mwwy.
-0R-
C�T An um arW yet N .. draw undesWei that a no um k rumMeW w olhemiea provided
PMe canaary
Pa+guuv'vd ,Ml piece mg wemeelremade In
a mile temporary comments For defrvary
This RaMorynyym Form was;frovkea by Patricia Miller „aa executed at
mesew
ewer Funeral Home, Inc. ar�wnam,
&
24 ChmWm St, take Luanni NY 1241E '..rr `Yet
fp�wff� W
wo is Wined by the funeral ammo'ea winged to is exaction
IMb have removed a compared cape of this AuMcamsta en Form.
The Posonle) ldenutsd Wwerii the peaanPl In coi adiepw2an,who by signing this AUMosb mForm,atl n)
to Me aoou scy and complaMnass d Me Irdomemon canard In MIN Auderkarbn Fora tend aahom ip the MpWy.
Signed Mae n Maya !W ,p
a o tNl .
�Lawrie v,
mMis
Ni
AwwY
Awwa
s x6s:
PWMiller
cwon.mnm.m rDmi
124415
a�u e
DOS-18934m . 04115) Page3a5
Authorization for Cremation and Disposition
nrlmd5am tde ra5a(ew�
Number_ 11hourphon Spvse
R. TMauMNdn antral in art Pumuent b Fuel Heats liretion/ROt(3)
d ,
U. The smming doom oc pviner;
J. Any eumiving child caffeine Years of age Of Wdll
a, AsuNMN parent;
5. A surviving Wbling eighteen years of and or oMer',
fi. Alewtully shown Gumforin
L Any Poste eighteen seem of that or older m iFir share in the estate and and i som,cloself in relanonahip to the Model
8. A only Israil fiducary of Me ladder
8. A alum Mend or real PTO has areculed a wtiner Nalement pusuant to Pu WIC H ealth l wSegian 4201(�;
10. A god Most officer of a county or a public etlmimemal special pursuant to the Sundyed a Cram Pmcedun Asia,
I AnY Other pardon vino is agil on benaff 0 Me deceased a nd whe has usewdetl a wrinen statement pursuant M Public Heeryh
tan Stal 4201(7),
fill THREE of Me ktbwingl
` ' J hMbyalRmit Mel Ycf Medece does" nUmabatlery, banery Peak. PowergR radiaaGveimplanc
OF mdieacgre acmes and that any ach merenals wpe removed morn the Vaeweion of his Authorarion Form. Famretonmom
made sprow to cremation may rauu In harm to has nemetcry and cremetcry pemonmi.
�tM�T
'e affirm that lnsamet ns heal been Oren to Islander Mill
asserted the remoal 0 any pemrel procedY OF Other sell dreamer whirls any cemn diamond helve do arty ham, m¢mberat Me
tleaasM efehabpmaerva. One Yiex Carl
is not reaµr9ide For Mamie alor ceRMml items from the conb'mer arkom oertemams MMe deWaaM. Pomanel irxna bRln try
�container orwlin Me norms ill bedaetroyM by lye(mametlon larocae and annotq mboved a%er cnmanon.
31�1 me hemb autho ' hand New Carol
v a wvw w
ro cmneN Me mmelne OF Me deaaad.
FINAL O SPOS T ON
TM arson aWhar¢eo to asceive Me MMW mmtm ate hcaeetl from Me mmabry Is:
Brewer Funeral Name, Inc.
Name'.
2<CM1urtlt 51., Lake -.'ou. NY door 5t&Bl%RTa0 AOSasa: Pocoe:
The cremetM remains a decreased still be gaamd ore betas:
financial
tiPoneny cmnreMryrson marred dove tloa nd hate personal al or0ntoaletl m
aumo 0the e
Me rwalab Bmwet Former Home. Ind, Is W>seazono
l�wy a by oellava
in amen orbd reaip easel.
eeebb[.Ramada
mmm e
OOSIBS&I(Ra.P415) Peas 2 MS