Archambeau, Howard E.G'
Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745.4476
FUNERAL HOME: _
RETURN TIMI: � -✓/
DATE & TIM E REMAINS ARRIVE O AT CREMATORY: 7_z7-Y Za /Zm�._
NAME OF FUNERAL DIRECTOR OR REGRISTERED RE310lNT DELIVERING-REMAINS'
NAME: .
If yrcli__
TYPR OF CONTAINER: **/il/'L--ftee,
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FLACROF DEATH;
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ESTIMATED WEIGHT OF REMAINS & CONTAINER 2ZOIL !
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION: 7- Z 7 - b7IA
TIME STARTED: �PoDM TIME COMPLETED: 3Q0/fM
PLACED IN RETORT: / m -----MOVED;
ZnnI OOY`�-
RETORT R 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 SHALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
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Authorization for Cremation and Disposition
This AuParhNon Form must be complaed And signed prlorro delWery OlremeW enrcrem ent
Dark: 07aiIM20 Number Q�o
Crematory Name: Pine View Cmmmory
Address: 21 Quaker Rd., Ouaenabury NY 1280d Name: T/97HTdIAM
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Carnation is tamed out by finding the remains of Me general and the counsel eeWing nc Marshall a barrel comber whine
Mey are subjected to Intense heat and flame. The heal and Name will Immn mdw eM consume everything essept bone and mql,
which en all that will m left after CmmNon.
Following crmall ft comment,will Wks re nable efforts to remove all of the hall his and One,material hom the vemaYOn
chamber, but come minimal dust and residua will likely be"behind The cnmakry wall wpamle IwNerdel end tOhaiOn mear'ul hwn
Me remains and Me i dryAft and breign maternal will be d'apOHd of as reduced by taw. The downward remains will low meNankalry
µWNiud inW small means and plead into a dMlgnmed container or um. Cremated remains Message am puhedrad Meg M
single fragment Is recognimmis ae maletal tissue.
OPENING OF THE CONTAINER
The crematory may early Open Me container holding MeunCremetW human remains In limited cTmmatantte,surd As to WrRrm the
Identity of Me dewased Or to ensure Mat no mandal is internal which might inure employees or"Mega Me counsel property
human remains am delivered Ina mnalmr whim Is not suitable for cmdWion mach as ceremonial or her All Me
Onmaary will require M mlro be m GM u at Me reaowed Into a suitable container re it the remains. The opening of a
entaimr erne mnamrm reman m reraina wit a mmwMd aemre a wdmu area will x sane in pdvary,win dMnm am napes.
IDENPFICAnON OF DECEASED
Name of Deceaard: Howard E. Archambeau Marital Sti Widowed
fan Known Address: 536 Old State Route 9, Chestertown, NY 12817
Piece m Death, Deceased's Residence, 536 OW State Route 9, Chestertown, NY 12817
See ®M DF ANA 85 DOB: OWS11955 DmedOeath 07QM OW Eedm WeMM'. 220
Dewiption of inekelecro mer in which remains inn be deuwrew
Florence casket co.-deluxe cardbal
PERSON IN CONTROL OF D SPOSmON
(Faanci al m mnhm oldrsndesitton, BONE offM Mkwri
amM1Ve am Me designated agent Of deceased desgnated In a Mil or wMMn instrument a icated Damsel to PWic
Health use motion 4201.
AOR- '— Me here no knowledge Mat me dermal amended a wrinen instrument pursuant to Pmue Health law SMien am1 or
mining directions for Me elimination of his or her remains and]Me are the puma la)having nobody under Pubic Haw Law
Sermon 4201 and have Me fight to auMm¢cremmon of remains Oft damned. MyrourmMfomhlpa Medeuased ism
blbxa:
Howard E. Archambeau
COS-180181(Rw. M2)) Page 1 of 3
Authorintlon for Cremation and Disposition
- (lineal fipnlhB list bebwf
Number. 3 pmiuiption: child
1. A person winited in when WnwMro Public Heats Lew 3eWm e20119C
2. Re survaing sppuu,
U. The wrhirp domestic partner;
3. why surviving Tip egMaen yearn of ache or alder,
<. ASuMving parent
S. A surviving sibling elgimen yeas of age or older,
S. A Lawfully appointed guardanl
T. Any personls)eighteen yeas M age or okbr writers to sham in Me estate and who lyare closest in raladership to the deceased,
a. A duly appeired fiducary of Me estate:
9. A ebro Mend or relative who has executed a writer statement pursuant tc Public Health Lew 3eTm 4201
10. A chef fiscal aut0.v of a County or a public administrator Measured pursuer to the 5untyete'a Colin Procedure Aid,
10a. Any driver peredn Who a acting an betaN of Me demescd and wbo has insentient a written statenrent Nelson Public Heats
Lin grown 4201.
(In// ,,
i�ff AA�LL THREE of the b Wwag)
INJe hereby affirm Met Me Ably of the dewaeed dxa net cown a barely, battery pack Cower¢II, raeuctism impart,
orgdioaNre device and that any such mateda6 were remouN prior to Na exewriw MMis Auft6u nForm. Failurebnmave
tlreaB Itarne prio!b cnmedan may Haul[in harm b thecrenrebry end crematory pareonnBl.
OlS vava affirm MainaovNons nave bean gwenfo John Aexander
warning the removal of any cerwnal pipets or canner thing of value which aM own signirp baled ovary family membefore e
deceased wishes to preserve. Pine View Crematory
summons,save
is not responsible One removal of cersonal Marc from Me stee a orhwn the remains bfdwdwWwd. Personal ibis left In the
mrdalnerarMM no remains Will bedeatroyad by me aMmOon pr«aR and Minot be retrieved afar cm Lion.
Me hereby summary Pine Vier Crematory
rowMr wave
Me Mremaa the remains of no decauM.
( nAiNovnofyAL)
Was funeral director to provide for deliver to and cnmtlicn by an allmm
m.tory,IF deemed necessary in the opinion by the funeral deal and to emend this form to pravlde the correct name and
addme of such alternate crematory.
FINAL OISPOMON
The peon autrariaei to maws Me cremated remains of the deceased from Me crermi is:
WMAmirander-Baker Funeral Home, John Alexander
Additional. 3N9 Main Street, Warrensburg, NY 12W5 Eleven (518)623-2W5
The aemebd remms of renewed will be dlwwd of as Michael
tuned in Warrensburg cemetery
HKK try,reason Of Merlon named share does not taM c Won of Me vmw amenm,
Pine View Crematory is aummmd to aline dowMcn of
shames,"Wea
Me mmaim m Alexander-Baker Funeral Home W delivery
in person a by registered mail. rn wwa...NW) Howaed E. Arohambew
ix»epr�a
WS-1e99-f(Rev, Out Pages of3
Authorization for Cremation and Disposition
llnea theCA
takw4r¢1
_gwe uMerWMPat aPe remains ere nm hialmel wgnin Izg can m eemagan,
Pine Ulew Crematory may disease 0 me remains In
an imaienbh manner, wM as oy sutlenN
CREMATION CONTA NEMRN
fle&&WQ mine Idkwmp)
Alexander-Baker Funeral
An um b W wed as a wMairwr Sir Me cremelai returns nw been Wrchaeed M1um u...._
and is desmeee as rolloas.
iNh understand uW if Me um Is tm aural to hol the entire cremated menams, an additional rigid container may So used he dNWy,
oN-
��Anumblwlretwnfi..ed ewe umalmnc PMensambpumhasM acNemvelaovHed
Pine Ylew Crematory mu platy the cremsed remamem
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a ngtl bmporary mndamer he ddiuxry.
This Auep aN FOrm"a owned John Alexander was exaction
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Alexander-Baker Funeral Home
38MINM e
Main Street, Wamemhur9, NV 12885
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eM Is signed by Me Nreral duet as where"to ib execution,
INia have rererved a completed wpy of Pia Auewrlxatl011 Form.
The perwn(al W"fiW hNow Islam Me person(s)In coned of dlepoeMen,who by signing that AUPor"Mn Form,albege)
to Me accuracy and completeness oftlw Informatem eanbined In that Authorization Ferm and auNOrW(e)tlm lon going.
Signed Mls 24th day of July ,20 20
David Baker
536 Old State Route 9, ChaMertown, NV 12817
WIINEgs:
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JohnAlexanderl
10038
HowaN E. Archambeau
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