Clarke, Dorothy L (2) Pine View Cemetery g Crematorium
Quaker Road
Queensburyl NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL NOMG: nS g
r "-- --- RETURN TIME 7 3/ 7pJll
DATE & TIME REMAINS ARRIVED AT CREMATORY: -�^20 NAME OF FUNERAL DIRECTOR OR REGRISTEREO RESIDENT GELIVERIND REMAINS:
NAME: _}� .IG. . / ef /G/14&
=�--�L� CASED
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TYPE OFCONTAINER: rxe �t
PLACE OF DEATH: 41VV3 /- NYIZS
ESTIMATED WEIGHT OF REMAINS S CONTAINER /.)0/465
PLACED IN HOLD: q PLACED IN REFRIGERATION:
DATE OF CREMATION: _ 7-30 Zi�-EJ
TIME STARTED: IIy (-/�-y/ TIME COMPLETED: A�Jn'/ .
PLACED IN RETORT: I/A/SIDPR. __MOVED: 41
RETORT S 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 SMALL HE RETAINED IN THE PERMANENT FILE GF THE CREMATORY.
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Authorization for Cremation and Disposition
This AU or4Nw Form munbe compM 4and signed Reform delivery qof mmai"forem aben.
Data 070MOM Number: �/ V
Chanel Name: Pire mCmmMwym
Meares: zl Owkx Rind.Discordant. NY 1l PMea (518)7ASMn
CREMATION I8 AN IRREVERSIBLE AND FINAL PROCESA
CremaSm is Umd am by lgacng the immune of Me 0%@ased and Me octa r MOag tle remains I=a credal tlromme where
Nay are subpCtBd W intense twat and dame. The Mat And flame FAR iminmW and consmm eWrydring except bond and maYl.
w hAch am all that will be me abr cRmacn.
Fdbutng crema5on, the aemabry will rake reasonable efforts to remove all of are remains and Other material Yeah the cannel
chamber,tW acme minimal dust and Rescue MII likely be kfl di The chancery will ermande imideMll and merge material Man
the remains and demonstrated arkbreign maser llM dupaed Nag resulted by and The remaled mMms will M MK IMly
IYJlaenred Into small pieces and p16M Into a designated contaneharum. OMllabd m mom g"mlly am Wlrsrha unUi no
single fragment ie recognizable a ekNe ilb
OPENING OF THE COMA NER
The remstory may coal open me container holding Me un. mamd human remains in limits a ncomtlhomed; anon as W amber tl6
identby of Ne dKeaaa mW ensure Moore material bshomed which might I hareemNayere or damagetM rem=t Mil , N
human mmslM am dNlwmd in a contaener which Is not suidable for cMMw B such as AwmwmUal or rental cpb{Me
msW W will"Ulm Mat Na mmWns M moved Into a vuNable candidate bNom N acupb Me remains. The tepareg Na
WMBiner a Me transfer or removal 0 remains will be cont oebre a whence and will be done In poetry.with idgmy and mapMIDENTIFICATION OF DEQSASED
NamF M d:
OaWry L Garile MCNbI SIeWa: Neer mama
laA Fresh
rWwn Pgdte¢s: 4403 RL ON Pala Ccmen(Town of Greenfieldl, NY I]BSB
Plant of Dart 4403 Fit ON, PpM Caners(TOMI of Damaged), NY 1R869
Sea: OM OF Age, Te DOB' 1DW1905 oMeWemM 07WOM0 Ed,Mtl WBIght: 461
Deformation ofm Skacmdlw N wall termare will be delYmm
(cyWM MVmWegmenucr� Me11Mwa Aurae Wo sins cw@p Ctemw Ccnlallwr
PORSON IN CONTROL OF Di�$Ulgb
(Ponm(a)in cmaN ofdeporl added ONE NMI rM'c l
I deans are Me designated aWt N has d 8SWd igr OIn a will or whMrihubumeM Amended purchase W Public
the"Lear Sweet 4M1.
✓-OR
/n sweet Mve no hrMWge that the deaaa execand a wrap instrument Rural M Peak Neatlh taw Sadism e911 ma
tamingdiR onsMNedmKmOnofhisrderremainsand IMe%stilepemm(s) MwrgprWityuMer FuaicR Mtaw
Season 0101 and free Me right to authrol rental ad Me remains W Me de¢a5a_ ayfDur mlaonsMp W Me Gtemed 15
allows'. Dggfy L Cob
Pall
DDS-0gBBf lRev. OA'15)
Authorization for Cremation and Disposition
preen Sam pe u.IMawJ �
Numtom 7 Cmmebon Survival wave
1. A Pool dominated in m Ag Pursienl to Pudk lMeM law Not 11130:
2 The surviving apnuse'.
L. The Sunni EameAC Palmer
> Any waning Gild metal Peers of age a don.
0. A surviving parent.
5. Asurvning sibling agreed years of sae or tltln.
S. A laMully aPPoinkd goaded
T. My proven lsl eighken yem of Ne w door emitted to share In the hope and art cl cal In relationship to the tlerMsed',
S. ANN aPPOlmm fiducbry INlM whitei
9. Adiew imnd w real wh)has exAl a within goal WRuant On Pudk Health law Section 42m011
10. A coal fiscal After of a coimlyar a Wbliat minimatra0r ammi PVSianl to Ne Sunopoly s Court PmWtlIre AR
NA, Any Min whown v.Tokading on behalf d we d3ceesetl aM and has maCNed a Arran somemenl puraYYe in PWk Hm
MwSemon41011T).
n( arAal ALL, THREE of me ltllwp)m�
]� it beer hereby Am that Va each,of me dawsM deny rot cant a label Mtery hat Palmer cell, radical lmgant.
' I IXradmtliuedeviCC eMNMedy eUG malenak W¢r¢removeC pnorbMe mBCWIm oYNio Autlho!/utlM Form. FaliUMWmmove
haaaeeta ,pdwb managed may mutt In boom by and chemabry and combat personnel.
NYe Arm tlullmtuctans haw been pen to Face 11. Wool �mr�rem
agent the removal of any Penance' [fCPeM or MnM Mty or value"No any Pe%n Si9rnng E¢Iow or any kmily member M\M
Mwrsed Mons to Pheserve. meW CRmamnum
IS rMpopon8ibk br Na rnmovalMPeheMel items hwntM mMaine/WM1nm NerMdiniMNe tl%ee5ed PB9orp11pms pNlntM
Caln/WI/vie/olvAlh Ma remainewlll MCY1IOyM by Ne epmpbn pIOEW phtl nnnotM /eMawd eXer Cremated.
Y4'J IIYIe Mnby eYMorW Pbeuinx CMnelonun FxmnrruAl
bcp ab are pmelne of me dewed.
FINAL DISPIXIMMI
no qmi mentioned to receive to nemeal Norman ohtlpPotential M1wd Ns comedy,
Name: Rural. thermal
Act T Sverman Award.CcnM1. NY 128l Phone 1518)854BI85
The aemapd remains MCeOpe]fall MtliBP09ed Of of Wi
Returned b the kmth/
If Wmy random Me person nomed e0m(17%hMaide Malawi WNe embedded pmeadme
Ptmvinry Communal iae@,MadelbgM(rta' eeimof
me pmamyW DonamoreFurl Herm. IM w Mdellvay
n++w•A.a..d
in green or by raphood Met CttMy L CYb
dad 1m -f 1Rev.Pi A'�a✓oss� Pop 3 03
Authorization for Cremation and Disposition
(���/ftM1 wrng)
�__VL IMb uncestand Net if Me remains are rcl cWmW w m 120 days of central
Piro mCrertatorium mry0reraw dNe remans In
M,eawww
an lmN able manner, moon as or s[etlenng.
ONE Ntlre Porem"190
An onWM used as a 6n wforlM crnnaW ranam has Men purchasedhom Dare arrow Funeral come Inc
am la deer as ml Brw mend um
IMb urMeal OwI O Me um as Ka small W hand Me entire creme remaN¢, an samurai mad wntamr may[e mend fa terminal
OR-
Jim umla near sent WrUowI Aft ufte "it rw unY wN adlcervhe Powed
Plwnaw CremabrWm my New Me commend rantln¢in
m.+.umeN
a all remgmnn central her dalirery
This AU omatron Form wee PWAsd by aWPtl. Censm"re ,� was uxNeda
Densmore Fuel Home. IM
1 Somman AMnue,Carl NY 1281E au.umxww
and is agred my has Norval tireda as aAnees to ik consul
INR have ordered a composed wry,of Nla AlMwrmatldo Form.
The pmwnls)mandfled sell Were Nep Mmm)In cmmmod o1 dYPo IWA.who q signal MIS AUMom mFwm, anegel
to the ammurxy am arrangements W McIMomutlon montaered In MY AUNmrhe Farm and auM s)Me breBolrrg.
Slgrred Mle 28N day of Juts . 20
Maureen A. TgnMns,
44 RL9N, P Ccmers.NY128SB
WITNESS:
1M10
Damon, L Cl.lu
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DOS-1898-f(RIN d15I Ppe903