Brtwitz, Barabara C. Pine View Cemetery & Crematorium
Quaker Road
Queensburyl NY 12804
(518) 745-4477 or (516) 745.4476
FUNERAL HOME:
---- --&—q'S---____, RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY:
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
iprE.NV
NAME: ..._. _. ___APFhQa}_ �YFT'MLT9
gL0
TYPE OF CONTAINER: �� (I �- Q( ^
ALMS
PLACE OF DEATH:
ESTIMATED WEIGHT OF REMAINS S CONTAINER_ IVO II^
PLACED IN HOLD:
PLACED IN REFRIGERATION: _
DATE OF CREMATION' 7^27- -MZV
TIME STARTED! d73 R1RI TIME COMPLETES'
pp 10rOeYL ,
PLACED IN RETORT! 07jyq i:n ---MOVED: 9JSApt
RETORT p IN WHICH REMAINS WERE CREMATED: /Ok.Y?R
V • _�
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN qB HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG aHALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
New.Wkawe
NEW VO0.K Division Of DAW UMUE ES
3TFiE°F DIVISION OF CEMEIEMES
° °°"" " Cemeteries
All NY t22lb00r
heagmne:"I lost
^ M9
Authoril for Cremation antl Disposition
This AU Wml nFarm must be COM M And egn6e prior b emlven or nmalns for Crefim.
°are, 07I2312020 Number 810
Crematory Name:Pine Yew CrentiOn
Address.Quaker Road Gueensbury NV 12804 Friona: (518)7d6 76
CREMATION 18 AN IRREVERBIBt AND FINAL PROCEed.
CremNion is remM out by amagg Vie remains o1 Nor demaed eM NO(broader hotline Me mnairo laid a vemetl angel Mies
sewn are sublacted tc intense heat and flame. The Rut and Mine are LCin and caeume ev Mg gaups lean and nMel.
coffin am all that MN be IOft after moment
Followng ammeter the oemaWry will take reasonable eHoeb to nnave all!the remains and other material dean Me changes
chamber, but same minimal dug and residue=it likely the lid MhiM. This nemebry van 9eperade nedenal and foreign material main
the remans and Physical icall and foreign material wd de d'msaaed ass m luiM by Wax. TM vemeled remaiirt MII Le meCMninly
puNeriredliner small pieces and pull into a designated conrevar or um. Cmn remsirm Generally am puts uMYm
all Rapmx Is wNnWW as sealedal Muslim.
OPENING OF THE COMAINER
The Crematory may only open the a nWiner holding me umCremated human remeine 'm traded urcumseral real as N confirm the
iM®ral of the deceased or to ensure Nat no mill I8 demand whieh miIllmhure employees or damage Me uematory properly. M
humanremai as a as dallval I n a contalnN which A not subble for crystal such As central or rental Casket the
msbry MII rp gin End Me mmtlnelike mow! Into a suRA bid contain b m k eaepb Me remains. The opening ofa
coal ner or Me transfer or ramJval n remains WWII be carcinoma aMM and MII be dome in all with digmty and mapa2
IDEWIFIGATNIN OF DECE GEo
Name of°ec au Baftm CBartft MCMeI BIeWa' DivtlrgE
Len Known Addws:16 Gillespie Rd, Middle Granville, W 12M
Plea of DeaM, 16 Gillespie Rd, Middle Granville, NV 12849
May OM ® F Aga: 74 Me: 01,W1946 OeM nDexn: 0121Y1020 EatlnMbl LNegPA 149
Deeuipoon ofcaskeumnWamr In w a remains Mn be dNiand,
Buffalo Casket Company—Alt container
PERSON N CONTROL OF OSP°GmON
(oommin )i cpµd!!sperm, marks ONE or the ldMvmpl
I airtM1YO are the designee!agent dNe deceased moderated In a MII or wrNen inpmmeM executed pursunt N Publis
HYM Imi Hecbon 0301.
Oq
WMe have no knowledge Met the deciased ea a wMlen iaebument targets to Puerto Halt law Section 4201 of
are niN direagrs for the disposiain of his or her remains aid IMe are the pemnds)having on"under Public Huryb Law
Recal A$Ot and have the right to agenaCremafan WMe remains of Me daa:anese My rmlaWnship WI deoaased Ism
fti w
Barbara C Barnyards
0084898-f Rey. id Pegs t of
Aothoril for Cremation and Disposition
fmprtawn did mu mww)
Number. 3 Desulpfon: ChIW aver 15
1. Mum deslgnatb in among pumu2MW PUNk Heats Live Selion A201t3),
a spouse:
m. They suamng dcm064e pane:
a. Any sanymly mlm eighteen years of ere or dtlm:
A A survione parent',
S. A sui Wool ln9 eighteen Rude M are or oltler'.
6. A feeNlN appointed guualan
e. Tepersomnly vA¢Orkrouaerears of age or older limlited m share In Me plate and oTO Were vbdeet m relationship m the de aw,
e. Adore friend or hall wthe
haseecutd a whim Germans rumored to Public HpM lore section 4201t11:
10. Achief face officer of a roomy err a Puma admlmsnrbr appointed pmWam to Me 6urmgale'a Coon PrmAue pit;
100. Any Mher peace wed g Hand On lWlf W Me narrowed a no who has welcome a wrihen Mandate pursued to Public Home
Law l`wi 41.
Maur ALL THREE of the Improving)
Me hereby rafrm that Me domr of Me Model aces nN moral a lmtlery. W"pal power mall, meivyre MplaM
or re3iwclrve dent and that any suds mammals way removed giar m Me"pNOce of thin blasphemers Foml. Failure m gape
tineN Pi Re credit may aeon In harm m tin oriental and Mahanadi pea W.
MVeaMrmtharmten ctions Mvebeenghwnm Merk J. DeSimone
payment the rengval of mr r premtl ports or order Miry of relw whirl any ream M®ral beWw or am mmiN member of Re
x 8 d shiner m preserve. _ Pine View Crato
is net aepMdbb for the remwelaPersonal lame from Me wMeiner fpeor r Mr am M MB defeaud ova llama left mute
MIdm' hM_w/r or after Me remains WII be dptrnyed by me Malawi Propose and"mat M raMpaa after nwplmn.
pyya Maby auMwlae Pine View Crematory
ro...rmx..d
by cmnab 1M rmrulp N1M Guvetl.
(ImMIOPTroNay
tins hereby Rumored the named funeral Mrsctor to provide for delivery to and camel by an ahemab
mamry, N deemed necessary In the opinion of the furrow director,and to amend MIs form to provide this correct name and
a"l o of such aftemam cmmemry.
FIML MMW ON
The person sphyUnd m recrve the campt remains ofMe damped from the oemdtory Is.
Nate;Kelly aertwip
Address: 25a Gordon Drive Hadgesvilb W V 25027- PMrc; (515) 34S o
The pammd odder Of tle we be diywsed of Me blbx:
Return to family
Nfr'artydamn Map ratedaboved net eke possession ddid commit mmairs.
Pine View Crematory bwlhmretlmgM Posspebnm
ummrem to Regan Danny Stafford Furwral Home by without
In yprwn or M ogemert mail. rr..+ranrww Barbell C aeMntZ
DW 109e-f(Rev. M20) n Page 2 Of
Autharlution for Cremation and Disposition
lb1diFl/tre awwMy
W' NNe untlerWM that ulM1e remama arc not clashed ways, 120 days of Cremation,
Pine View Crem�n[orl may shadw,of Me renew in
an lrreNevebM manmr,sW wby walMlnp. �
CXEXATION CONTi XERNRN
lami aNE any fawrrlrgl
Regan Denny Staffoml Funeral
An um to be used as a wrXeirrerbry.vemadd nmeim has been puMaeeahwn u.......
and is deemed wtaloea:
IWe understand fun X Me an re loo small to Fdd Me eMYe o emehJ remabb.an adllural reed academy mr may a Red M deiwry.
DB-
^ arum emryelpmrM Iv�e adwamnd Melnm um is paalwetlmatlerxiwvrovided
Pine View Crematory all place the cremated remains In
wrwa.rn
a n9itl Nmlwary mmaimr p dN'mm/
This AUMorew Form was pmrged by 11 J. Dasimona way exewtm at
Ragan Denny Stafford Funeral Home
53 Quaker Road aueenebury, NY 12504
am is agned by the funeral director as wassw bat mantras N
Mae have rereivM a completed way of dais AUMorhe Form
The paryan(st Me Wblow b/all tX panar(s)In conlml of dbpwMlon,wbo by signing this AUOprha Farms 00i
to the actuary and mmplMsmss ceIM MbmuWn contained In Rely AugwtrNon Form and autherlwlet the fewgolm.
signed this Yard day July , xo�20�,
Kelly Bartwitz
2413M7 Drive, Hedgesolle WV 25427-
e•mr Ms,, yr•
Mark J. DeSimdne
p«ru.rrrr� m.�.amy.r.� 111919
Barbara C Berr i2
D05.18984(Rev. 04R0) Pags 3 of 3