Bates, Helen Jane Pine View Cemetery g Crematorium
Quaker Road
Queensburyl NY 12804
(518) 745-4477 Or (51B) 745.4476
FUNERAL HOME: _-C�l Gl
--- RETURN TIME:
DATE a TIME REMAINS ARRIVED AT CREMATORY:
_019
NAME OF FUNERAL DIRECTOR OR REGg1ETERFO RESIDENT DELIVERIND ReMAHUN
NAMEI
CAEER
TYPE OF CONTAINER: 4J[/R�—��_)/�11 ^-
PLACE OF OEgTH: `j —A4VL
ESTIMATED WEIGHT OF REMAINS A CONTAINER_
PLACED IN HOLD-
PLACED
PLACED IN REFRIGERATION: ems' --
DATE OF CREMATION:
TIME STARTED; - 09V5-Y} TIME COMPLETED: 1070t9✓H
PLACED IN RETORT: _01y
—4F --__moveD: _ 9�/SP4rH
RETORT IT IN WHICH REMAINS WERE CREMATED: _
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 4E HOURS
FROM TIME OF ACCEPTED DELIVERY: _
NOTE: THE CREMATION LOB SMALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
York Sold,
ent of
Date K paewmaner=na.ml:
STPTEOF Division of DIVISION OF CEMETERIES
OPPORNNIM1. Cemeteries Oenousnilrs
�e At WWI NY 13 all orm
Teleµone:15161 a 74-6226
Authorization for Cremation and Disposition
This Aug adm Form must be completed and algnetl parlor IN delivery M nmain$for cmmellon.
Date: (k'�7 1Y , 2�w Numder. �Ut
OremMary Name: pine Value CrematonYm
addren: Quaker Rand Queensburv, NY 128W Phone: (518)7454477
CREWnCN IS AN IRREVERSISLE AND FINAL PROCESS.
Crematun is carded out by plating the mrwins of roe depned tole the wmainer MlGng Me remains Into a mre ion mamber Mom
May are subleclad b ,marks Mat a no flam e.The heat and fie in e of 111 nclnm %antl consume av hing except bom and Will
which am all Met will be left adult cremation.
FWowilq venation, the U Mtary will take mrsonabl¢eRona IO mmove all of roe remains and other mMdal kom Me Cre ton
Nambm,Wt scme minimal dust antl residue kill likely ON left babied The lawmakers will separate inddental and foreign material from
Me remains and Me mdmMm and foreign matenal will be disposed of straitened bylaw. The aemald remains will M me¢Mnicaly
Foulver'uM into small Maw and INamtl into a deni8nMdwMaial or um.Cremated wMllm generally am pulveda until ma
sins Nagmant is Mognluble M skelM ltlOw.
OPENING OF THE CONTAINER
The lawmakers may onlyopen the container baa'my Me urlidren ted human remains In limited Cmumslances, sam as to conerm Me
identity of the borrowed or to ensure Mat no matenal is enclosed which might injury,employees Or damage Me uemalwy,prepatp if
human remains are delivered in a cograincer which is not suitable for cmmaticn such as ceremonial Or ranYl caake6 roe
mmyq will require that the remains by moved Into a suitable"r tnw bebre A amdm%taro remains.The opening of
container or Pe transferor removal of remains will de conducted WMm a"mass and krill be tlwe in pnnry,with dignity and moved
IDENTIFICATION OF DECEASED
Nameof Decesaed: Helen Jane MORE MCMeISlalw: W'Javred
Lae Known Address: Feeder Vleve Ayt Hudean Fall NY 12839
PlcaaOeafn. Granville Center for Rehab and Nursing. A MadI6M Street Granville NY
Sex:p Mpp F Age: RA DOD: 1000ftff35 Date of Death 07121 Estimated Velgm: 93
Deslaiplen of ww ntahw In whim remain$tan M tlaikered.
ffja sCuH . CnS� , Ptywood60grlw - Co4FtD-�OTwi
PER80N IN CONTROL OF DISPOSITION
(Posel No M fofta csil, nuffal ONE same Mficlo )
amNJw are the tlesignated agent of Me decea6 integrated In a Wit or Wilson IneWment exewted Inherent to Pul
Hm M Lew Small 4201.
-OR
0AIAve hake no knmm Whet the demaaaa exeruled awraen instrument pursuare to Public Hearin Law Section 4201 or a
Sxkci 4201 aal nld halve the for the W cwnoe:his or
of Me rema and highs m the aeceeesed�WIal.nMati nshiv to
b�"W Is ae
rollow
Haley O Ba
ttle
mNm.a
DD&lNB.f(Rev. Gulf) Page 1 d3
Authorization for Cremation and Disposition '
!Insert fmm mexxbekw)
Number 3 CesuetlOn'. dilt h>eu"
1. Aperson designated in ermine Pumi to Public Heats Law 3ation 42DIP):
2. Tab surviving spouse',
22. Tur eurNnng domestic parpter3. i
e Anysummon w cold eighteen years of aPe or Omer:
.
surviving parent
S. A surviving aiblmg effort sense of ape or older.
0. A lawfully appointed guardlom
T. Any posts )eighteen years of age Or Older ever N atiere In the a to and earn avers domM In relationship to We devemed:
0. A duly appointed Wwary of the estate:
2. Adom Mend Orrelalive who her,examined a women statement pursuant to Public Health Law$ection 0201 pti
10. A one(ladal officer of a county or a ruWIC administrator epasroad punuanl to the 5unogete a Court Procadure Ad:
10e. Any Nher p0rm wMls acting on behalf Of the deceased and who has executed a written d%emeM pursuant to Ii Hall
Law section 441(1).
(fmfier bl THREE og)
gALL
Arm hereby affirm that the body Of the processed does not Contain a bal battery FaCk, power call, radioactive implant.
ormacactrve deal and man any such materials bore removed prior to PB execution of Pis AUPwlaal Form. Fallure b remove
Mein,Home prior to mmatlon may mult In harm We Na dependent and dmm=7 personnel.
&y)—IANe affirm Net Instructions have bean glum to DONEENS NIKAa
Ansomporwou
reeert the removal of any pwaonal Vo as other MMp of value which any Person apnbp belw or any famiry member of Me
demasehwishe erpreaeve. Pane Mass Crematorium
is not respormal Am Me remove of pmwnal arema horn Me Conminer or from the remains of the daceased. Peanda at theme lea In Me
conUtn"or with Me remains will be M4W by the mmatlon parameters And mbi end cannot Wareved Mail .
r samara
PELLING hereby authotlm Pine View Cremabnum
1!/to[meats Me remains of Me disposal
FINAL DISPOSITION
0Ttenaum to reserve the uemest remains of the Acporal it=the pemamry is
Nam: Cei I, / e itV h Xf,[ vw-ddrrn 4411 1 A.ev
Toe uemeletl remains Od amd an de disposed otasfOlked,
Re Faun -,i Il e7
If W any on the person named above does rot asks Possession dither mmMd remains,
Pine View Crematorium isautMmWtogim son nd
Me remains to Carleton Funeral Home Inc decisively
in penes or by mglswred mail
Helen Jane Bawd
Dos-15 f(Rm. 0L15) nrmsw Page 2 M3
Authorization for Cremation and Disposition
nmralare bbnm
Awi
, MK IAsNe✓nderstand that if someone are not maimed Winn I W days of cremaron.
Pinevmwcremafanum may dlsnob of the remains in
en irreth.a.en manner. a✓M a.by eranmaN9. I
CREMATION CONTAINERAIRN
_ado Wi
FF�Q Pn✓mmbe ue¢e.aammeinermrme aremated rename nae been purrna.eo loom
and is described as bWwn:
Me✓ndenteW that if the✓m is too small to mod Me allure cremated cool an additional n9id container may on meal bor dallwry.
oO�R{-�(�
XI'Ifµ Pn um is not yet purchased. IM/¢untlentend Nat if no um is pUrUd6ed mOlhennb provided
Pine view Crematorium wN Coca Me commend remain in
a isid nmpo r wnumer for calvary,
This Authorization Form was prowl by DONEENS NWAS wasesecundM
Carleton Funeral Home, Inc%
88 Main St P. O. Sox 61 Hudson Falls NY 12839
and is signed by the Nnerel di moor as wombe to its execution.
IM1Ne haw removed a completed many of this Authorization Farm.
The Persons) Identtfntl below Islam Ma Merchants) In control of dismiss III on.wM by eighth this A✓MwlesOon Fam,Whei
to Ma accuracy and complahnns of Me Nformancn combined In this AUMod"tl Farm and authorans)Me foregoln9.
Slgnedthla PO dayof July . 3030
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r 2`"G%YIAx.k-lTr, l2dr �rr-s /v/� iiY- 6S zl IG7
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DONEENS NINA 4Z
S ��
Helen Jane Bane
DOS 1898 f Reci=15) Pape 3013