Adams, Anthony Pine View Cemetery & Crematorium
Quaker Road
Queensburyl NY 12864
(5518) 745-4477 or (518) 745-4476
FUNERAL NONE: _UrCVJ_Q/_
_, RETURN TIME: 01071E
DATE b TIME REMAINS ARRIVED AT CREMATORY: _ 7^29 ^ZB}p L/ p3D
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
_ , /l I_..--
NAME: - '�'L% "•Gh✓ G • K/JIG/11S
r s GAbFp �
TYPEOF CONTAINER: / A4;H �p 44 S/G eralr E;
PLACE OF DEATH; LL OW e �O L4k_c Lk 'ZP/n.e ay A�
ESTIMATED WEIGHT OF REMAINS b CONTAINER 20v
PLACED IN HOLD:
PLACED IN REFRIDERATION: �p- _ y �ary'1
DATE OF CREMATION: ap- 7g2p /
TIME STARTED: 127/"11 TIME COMPLETED:
PLACED IN RETORT: 07/0'# ----MOVED: 0 O ryE
RETORT 9IN WHICH REMAINS WERE CREMATED: 9h„ /Pck
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 PERMAAENT TIED OF THE CREMATORY.
Nievo
0.peF UM Wv RIM
NEWF Division of DmgloNµFam.IETBRaE%
gTATE OF madam r
p°PORi0N1iY" Cemeteries `h'nenaAcrIlde
sysueew.YDn.mm
Talam nlewl4al-kch
aww.ommgw
Authorization for Cremation and Disposition
This AuNonmbm Form must be am Named and elgrsa Drawb deellipwery of AmaW for cmmdd on.
Date. 1/29Y2020 Number ()'D�
Cremamry Nalco. Pine View Crematory
Quaker Race Cumbersome NY 0804 516745uO7
Mdrew: risen
CREMATION Is AN IRREVERSIBLE AND FINAL PROCESS.
CremNion Is demand oN by among the remains aMe d eW also Ne container hoWirg Its mma'm into a aemalkn NPmbtt ntiere
they are subjetl W intense hear and flame. The heMand flame will NeimMW and consuna sv ing sarapt team and metal,
winchenall MkwglbeleftaltarG a4on.
Following nena4on.Me aamamry All take reasonable eRon¢to remove all of the examine and deer matmi from Me one n
Uanber, but acme minimal dust and residue wall likely Fe Its behind. The consistent wail separate hood land foreign mate ll hpn
the remains and Me incidental and breign material will be disposiFSas modest by lbw. The crmmad mr ns Ads ben anYB
pNVMmd into smell gece5 and placedmes a designated corommer or on. Crt ate remains generally am cola use no
all fragment is rxognizable as skeleh l tissue.
OPENING OF THE CONTAINER
The uemamy my only open the container holding the unummoted human remains in limited circumstances, such As to 0.Tgrm Ole
identity drum summers or to ensure that no material is er lorded which might injure employees of damage the crematory pmpedy a
human remains are delivered in a container which he not suitable tar thermal such as commercial or rental casket, Me
sstory will reulm tMe remains be moved Into a suitable cont before it befo it acOpts the remains. Theopeningota
samurai t er me tranarer or removal of remain$hen be conducted afore a winners and will be dorw In privacy, with dignity and respM.
IDENTIFICATION OF DECEASED
Name ch observe: Anthony Adams Mahal Starul14Once
Last known Mtreu, 504 Howe Rd., Lake Luzern, NV 12W
residence
PIgR of eath
Sea: flat OF Age DOB; 913155 Data of Carl 7A7,2020 EstimalN Mi 200
Oerdmpem of deNedc iner'in whits ml will W deft ered.
McDonald basic Cremation Container, no interior
PERSON IN CONTROL OF DISPOSITION
(Porsm(¢)!n wnlaV o(d'apaRbn, pEy ONEdaMy rabwAg)
I amNJs are Me designated nosh of Me dammed designated in aan or vmRan Instrument convicted All to Public
Health Law shim 4201.
eM1� BA kNle have of knowledge Mar the demawd eaeMed a written instrument pursuant to PUMic Health Law Section 4201 or
AS containing direc4ons As Me dammad s of his or her remains and Its are Me Me (s)having WnnM under Pulds Heats have
SeUbn 4201 Pe have Me flight to auNor¢e bane n at the remains of the d� Walsh amhip A the hseaW Is ac
follows'.
Anhony Adams
thead
WS18gaf(Rw.OSl15) Page 1 of 3
.Authorization for Cremation and Disposition
frMear fulloa4ry
SJ_Mass undennnd that it the reasons are had aelmed whin 130 aaye of cremation,
Pine Yew Crematory
an irMricrabk mercer,asub as by cot ng. »n neeren may dapose of the reran in
CREMATION CON MMENIIRN
undia ONEdtlro lammead
M too be ub] as a¢aUiner for the vemaled remains has been terminated Imm
and is remained as MloA
I/We unceratap No if the um Is W small to hold the sere aem remains, an additional nad consumer nay be used for"Weary
oa- n
, M um is has wit NYe uMgesnd Mat X an um Is p"aW or dhenatser prewar
Prow am
Crematory
we plaw the vmmated remains or
aweaonayl
e ni ampor m y mmelnw for Mpvery.
This AUMorbSMdan Form was prcWded by Patricia Miller was executed at
Brewer Funeral Home, Inc.
N Guch St, Ire tjmerre, NY 12M
ens a agn el by the Nnerel all as weneea to by executen��
Few have rest a completer way of uls Authorization Form.
TM poson(el iden4Md below ishre No Me (s) in wrNd of ciromium,who by Waning MIS Au mahan Farm. ap US)
to Me accuracy and completeness ofMa Mna atl mrdalned In No AuM zmtl Farm and Mythom ad the forpatng.
Signed!MIS 28 day of July , 00 �
Anthony Adam
Ad r
WRNE55:
ME MilMr `1T1'1�_I[MJ�JNf1
gae•wvnw..i Ins+awwmw.d "
a12i85
Missouri
Anthony Adams
DOS 1 Seat(Rev 00115) l age3 d3
Authorization for Cremation and Disposition
(lrugrf/ram(M list Mow)
rvambm 3 Desorption Son
1. Apanondesignated in among pmarmad b Publit Health ltw$af ion argagg;
2. admarthe
A. The wmWng Miami"Won
a. Any
yMHN'nO ChAd eighteen years Wings,Or olden,
5. Awarni warning"real
surviving mbling eghteen years Ofage or older.
6. ANMully 81dationted guardian;
a. AnytyapsanteiOmnyears Of age or older mthle]to sherBInMB esbb and who iWare earned in rBlelioneM1ipbNe EB¢ysp;
a. Adis hand or Oman olNe estate'.
10.9. AtlOee hand eletiva Wi has annealed a wrihen elalemeat aura t to Public Health taw Sttli0n 4201M
103. Any oµeivalrsonwo coumy or a public adminiri apnanted pursuant to the 5wroaate'e COutl Prc¢Eure Act,
4W Sei A201(]�o is,atlirg on Eehal!Wi Netleceggetl Ind wM M1ae exeWleO a vnitlen slatemenl pusuam to Pudic Health
Am ALL TH( E ofMa Mam ingl
liAllAlleMonday affirm that the body&µedonea¢ddoes ad contain a barony bahary thd, power cell, ardiaatlWe impose
Or 2tliaal Mines ant mal any su01 mltyralaware rBmwerprvpµegealim Mµis Authoritarian Food FallunbnmoW
days" bonds glwfa cremation may may In Mmi 10 Me mandatory and ce gperaaanid
^ur/ IAW aMrm tha11r2bugione have bean Pieces Miller
given a
r iq Mi normal N a"hamnm �voAano
Fins YcmirrCrreemat ryerming ervawe Mlidr envperwneiemna btlgvm any lamlr mdnNr ddp
d.msed wian.smpresem.
IB no1 n.poneibl.Wrthe rertnrvm WiperaMnl ndnsM1dntlremnUNeroi M1Or�nM rem.inaoltne deceeBeO. Panonali mlea In Ma
1r morrmainerarwlµ the remains will be destroyed by NB GemNon PrOme ant Norma to nblevep after assumed
4 //// Iry/e hereby vaµcrM Pine amo Chammay
a esh+l
ro.mmm Ma rem.Iry Of M.a.aea.ee.
rIN asPgeTo
TM Mason aNM1m¢ed to romme ge vmwted rtmoti a arms dBceged hom he perpglpy Is,:
Name' areWa Fwym3i lame, Ina.
.
Addreu. N ChuM SI. Lake LI¢em, NY 12800 5189 2yM
Pyomr
Tree rsemaled remains M dem((uatl ama be diapped a as Indent
i� ;
T acd -la y@ ./
It as any mm to µvpn named abxaB dXe day lake PONea9pr a NB rymptod rmm
Pore New Ctemalpy era•
Bream Funeral Home, Ina IB euµMBed to Bove Israeli of
Me ranlalnBa by delrrery a..W�..a..a
in pemn a by regiateree men.
Anthony Adams
MS1M-f(Fam. =15) aa+r� Pop 2 of