LeRoux, Kathleen M. Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: l AJ)0A
--_ _.._ RETURN TIME: nJ-N 4�
DATER TIME REMAINS ARRIVED AT CREMATORY: -,Zpw
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT—Y DELIV9111140 REMAINS:
NAME:
��jj
NAME: /FpN _)A _e79
TYPE OF CONTAINER: //4J_ h }j
PLACE OF DEATII: ._yr —
ESTIMATED WEIGHT OF REMAINS R CONTAINER /S6IAS C L Y FGI//I�
PLACED IN HOLD:
PLACED IN REFRIGERATION:
-- `
DATE OF CREMATION: /-30'z02U
TIME STARTED: O 75- J#, TIME COMPLETED:
PLACED IN RETORT; d9ZS/fq __MOVED: _L/z dM
RETORTkINWHICH REMAINS WERE CREMATED: S Po✓lam
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE THE CREMATION LOG Sxul BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
Authorization for Cremation and Disposition
Irs,nnmva
mm_w
Me AlMalnxpe Fwm muserbs canpow short slgaedprdr m dalh(r,yWremaNa berslnagon.
Dote: � NumEx.
cremamiy Name: 77AKJ/f�1 �'QPRnATdku�(
Address: �/ D, nXf..e 1)K
CRE MN IS AN IRREVERSIBLE AND FINAL PROCESS.
Commission a coined out by lading Me remains ofMe deceased and Me container holding Me remains into a
cremadan chamber where May are subjected to intense Mat and flame. The beat and flame will incinerate and
consume IveryMing except bore and n mal,which art all Mat will be left all cremation.
Following cfemaMn, Me crematory will take reasonable efforts to rtv,mve all of Me remains and other material from
Me cremation chamber, but added minimal dust and residue will likely M left behind. The crematory will separate
Incidental and foreign morainal man Me remains and the industrial and foreign material will be Mellowed of as
required by law. The cremated remains will be Mechanically puWeh¢ed into small pieces and placed into a
designed container or um. Consisted remains generally am pulverized unit no single fragment is
recognizable as skelebl ensue.
OPENING OF CONTAINER
The crenhebry, may only open the container Mkkng The uniremeled human remains In limited circumstances, such
as to confirm Me identify of the deceased or to ensure Mat no materiel he encased which might injure employees or
damage crematory, prowrty. It human remains are deIhamNI in a cordainer which is nm sultable for cremation
such as a consonantal oriental waked,Me crematory will "alternations remains be moved into a sutiable
container before it accepts the remaire. The opening of a container or the transfer or removal of remains will be
conducted before a witness and will be done in pmary,with dignity and respect.
IDENTIFIGA1TIM
ly OF O/E/CEASE
cre I
Na of Desoea aed. T 13YAGCFfN Meall SIeNs:A/f✓-iQ /YANK
Lem Known Assumed: � [.t4 .fFnh J
Picea Death: (I A6 lti H /v.l �
Sax: Elm NLAge� Doll: • //d,1 oexaDeatn: Estimated Waghk—
Deuriplio�"n�a�mntarin�m,� In ha"hich reasons Wit ba delivered:9-r I Yeu.7%Ftd� kK MI /9MA)£'(,
PERSON N COMMOL DIE 0121MOSITION
lPeraon(a)in mnlrworey mun, pgMONEofinerwmwirgl
I aM We are the designed agent of Me deceased designated in a will of Will instrument executed
pmauem to Public Health Lew sedr 4201.
-QJR-
heve no knaaledge to the dacaased executed a written Instrument pusuant to Pudic Hanson law
Q4na 201or a will containing direction ; far Me dispassion of his of Mr remeiw and 2ua,up^axY41/�
DT 1, mew cillph pMvrf pelda
WJa tlihet 'rf tps remeWS are gaimatlwi1M IM ditd sdcremstion,
(ems bys ( 9nu/d✓ may dispose of Me remelrte In an irtaVievOble manner,
suM as by emtledrp.
CR@NATION CONTG NFRNRN
(W$19{,ONE d IhB(NbWll y
-�1�( r-J�y'A. An um lO bB us!ede5 comm�erfirtlre CteinBlatl RTBins hBB bBM Wmllaeetl rmm
N
eaA laeP� ✓e BIY� IB dBBcdbed Be fOlWNe:
r+i rss wrE
VWe untlameld gNl gtle bn b too snmll b hob the onfi a caneOecl mlrmllm, an addifiaml rigid weather may be
ueetl brdeliveiY.
-0R-
An um has mtyet peen pumbsaetl. VNs urAareterid IW Wewo all p laat e Nuem c irse am avaa remains In 5 rigid ptffrpDrre ry
mmeinertar
EelNery.
TTIa FWwtivlbn Form was a wbn01 �if 'cj a r,�
wesezesumJ el(S.iwYbreW /i7 'ff
m,weirvm.anm+l I?h � mM kelmetl by tlniavY d�aclu
es wNie�b im maNun.
IMe have mwlvetl a completed copy of this AuthDrldgDn Form.
The parson(s)IderNaed below Iahre fee person(s) in control of dkiffee , who by signing If
Audmriragon Form, altanths)to Ne acouracy and completeness of be irdormallon comabatl in this
Autlrodeaaon Form a�or¢ela)�s'forepOlrg.
aipW.a �tIQ'of J0./
teol e v1 dS, If n ,AI f n a of
37 /eM
Mama
Try1v Mnw aka
ONu
vRSYtNna
/set
WRNFSg:
oosusau ra«.01110) ,rssowe nsesNs
I and we ere the parmangg havklg pretty, under Pubic HUM lav eaMbn 4201 and haver M a right a eu0lorbe
crenatim atla nmaimd(s dereesU. WtalTlwtim4ldaMM.decsuW bUydbws:
(InsM fipn Me psi lebw)
Number: 0ewipibn:
1. A pemn designated in w fling puasuaMM Punk HUM seaan 4201(3):
I The surviving secure:
U. The sumving domestic pander',
3. My surviving the agFteen years of age or oeer:
4. A surviving parenC
5.A surviving sibling eighteen years Gage or cider.
fi. A lawfully appealed guardian;
T. Any patients) eighteen years of age or older sMNed to share In Me estate and who lean closest in
relationship a the deceased.
a. A duty appointetl fiduc¢ry sae estate',
9. A dose hand or ness"who has executed a anted resources Contend to Public Heath law§4201(7)',
10. A Chief fiscal officer of a county or a public edmmudestor appointed pursuant to the Surrogate's Court
Procedure Act;
10a.My other tenon who is aclln9 on behalf of Me deceasctl and who has exectled a when statement
pursuant a Pubic HUM taw§4201171.
( ALL THREE of Me blowing)
Me sreby affirm that the body of Me deceasetl does not contain a Utlery, battery pack, power Cell,
radoactive mpant, or ndieedve device and that any such matenals ware removed prior to the"another of has
Aulfwmaten Fonn. Fallure M remove Most hems prior a crenugon MAY result In earn ea the cramafery4M
rMtmery, Personnel.
W e hereby affirm Mat instmdlons have been given to pun.wd d ,r ) [ a
regaNing the removal of any Personal prop" or else thing of IPe which any n signing i am amity
rtamsr INtM Oecemad wisnesb DreUrve. mnwurvro+.ly^ `t"0 'utu' is
snot
responsible for removed of personal ileme son is container or son Me nummim of My dacoasetl. Pareonsl itatro
Ind In Mt container or vital Me remains will be destroyed by Me watched Proceeds end"Most be rumn"ad
after cremation. /1 n
QMe hereby autlarlA lewmdvnn+l � l <enR.@M Fa'/ Mcrimab Me
ren`a of the deceased. ��11
F eMLDISP?�¢ TON ••
The person atph ed Mreceivp Me cremated redeem a is deceasetl fiam Me wenistri e:
Name: �; � l(C470, (Y/�l � -
Andnn C�C Pisani 7fX7J]f
The vertalU eameee aaeeeaend wgl s dlUosad taw fdbws:
,Qsw - do 1
Iffer Uyaawn,MptNaattamad does aWm pmaeman of Me cremated remains.
a Yna+l Jr/cJuc.+s .Q£hr1. is embedded to give Possession of the measure to
A""W Dim"ay by denary M pence «by beatere/ed I.
q�Ty�Gf� r1C
pdatre.N a...anm sy:zdr