Mattison Sr., William B. Pine View Cemetery & Crematorium
Quaker Road
Queensburyl NY 12804
p(518) 7/45-4477 or (518) 745.4476
FUNERAL HOME: _( [.//Q RETURN TIME: /I e-
DATE 6 TIME REMAINS ARRIVED AT CREMATORY: -I-
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
a&iIG 1--on �1 54_____.—.—
NAMe: ,_III:<„+ 3. M<8:yHgqJ R- —._.cnsE01i7G _
TYPE OF CONTAINER: 4ftlP446�.�L {y x � I ladddl
PLACEOFDEATH: ,7/ ��� l�p ��__p Ey , �.�� _ /7
S-
ESTIMATED WEIGHT OF REMAINS 8 CONTAINERS /A 5
PLACED IN HOLD:
PLACED IN REFRIGERATION: ___ 2/09
DATE OF CREMATION: 7-/T0 -7:ADW ,�'J ,/�TIME STARTED: �7p��ir1 TIME COMPLETED: 0Dfji
PLACED IN RETORT:
RETORT IF IN WHICH REMAINS WERE CREMATED: �K
DETAILED REASON FOR DELAY IF REMAINS WERE CRE 'MAT/ED MORE THAN 00 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SHALL BE RETAINED :N THE PERMANENT FILE OF THE CREMATORY.
4 c yort stare
IT�������111111 Detrainment state
EWYOAK Division of DIVISION OF CEMETERIES
srnraoF c°m ..""
°" To. Cemeteries m rem
:'IFIa1.,.a22e
rmmaor.nyyw
Authorization for Cremation and Disposition
This ArWmdaaon Form must be a ple and signed poor m dWi r of mmelm He crmnanon.
Dare: 7'29 "2c$U Number: SM
Cremelay Name' fineyl"cmmawdum
Address. Quaker Road, Dueensbury NY 12804 owns: (515)745-0477
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
ucareoScoed ttonrreg off�se'le'att and flameIng the m�The hxt and flame wils of the deceased and the
allna container
mes andmconsume eve the mme�w krMna cremation chamber metal
y are somation Second c ryno g remati nc a eon matak
wMch am all Net will bs link east cmmatlon.
Fdlo Vtt non, the cmmatory be take reasonable Womb remove all done remains and other mamnel from has me On
Member. Out apne minimal dust and reamue will likely lb Ire behind.The consul will separate incidental and faragn m dalM1
He remains and Me Momentum and mmign material will be Mspoud of as required by her The cremated affairs"if be Lam®ny
pulvarred imo amen piece¢and placed into a designated container or um.Cmmemd remains genamllyam pdbsNed mouth no
single fmgmx is hamgmmble ae sW ml tissue.
OPENING OF THE CONTAINER
The mmaldym oonly open the wnWlnIN holding Me urvGmmated human mmain¢in limited tlmum5lanma, such as t0 confirm the
Wholly of the de sec or to ensure Met no mamnel is ends¢ which might injure empbmm or demg Me vemelOry property It
human remiiM am delivered In a con inerwhlth Is not suitable for area Won such as cemmonlat Or rental casket the
mnatary will require Mat bee amain be moved Into sulmbm conmineer Wore It sees"Me remains.The opening Of
combiner or the Ironer sirremoval Of e ins win be anaerobic berets awMBes and will be done in pinery,whh dignity and m9(Rcl.
IDENTIFICATION OF DECEASED
Named Dxeased: WIIIiamB Mell'Nan $A ftismlu¢: Wi]r
Ise Nnokn Aderea¢. 14 Medlson S Mel GmmdIe NY 12802
Pmcsd Dears Granville Cenmr for Rehab and Nureng 17 Madison Steel Granville NY /2g3S
Sax:i3M ® F Ages: BB DOB: n911811931 Dared Oealh 07aWO20 Estimated Wersim.1WIL
Description of mskeVwnlainer In which remains kill be mitered.
GA,,) 13k .p9 w,�e j2l y ro rke"
PERSON IN CONTROL OF DISPOSITION
(Porxn(aJ in for ddisgaNlon,"No ONE dHre l fow l
emkfe we Me d"¢ed agent of the demased designated in a hall or Yemen insWmats eaaN1M pumuam to Public
Health law SBrgar,4201.
-OR
I _ Mike have no knowledge the He deceased eaecWed a win tan instrument pumuam NO Polite Heath Law Section 4201 or
II containing directions for Me dbpo9tion of his Or her remains and has are the pe rel berme flnorily under Public Hi hew
Section 4201 and ham Me 4to to auhomer cremation of Me remains Or the demased MylOur mlauor iP In Me deceased is as
follows:
William 8. Madison
Minimal mat
DOSISS&f Mw. 08115) Page I of
Authorization for Cremation and Disposition
peon from me awemow)
Number 06_Description: S (
1, A parson woMated in unting pursuant to Pualc Healm LawSMIM 4211m)',
n The sunning spouse
ga. The wMving membrane banner'.
Any surviving
Cold eighteen years of age or was.
a. A
S. A surviving sibllip eighteen years of can or older.
C A lawfully appointed gueNmni
T. Any pawn(r)eighteen"am of age or older arMled W share in lM estate and ship lyerc comes(inreatonMlp to lM deputy:
he el
9. A dax d o appointed
move who t
A has neWWm a rw an statement powder o Public with Lew SatliW 4201(7),
1D. A chief(iswl officer of a wanly or a public emrMnotraor appointed puAWnl to me Stnvyate s Con Procedure Alf:
the. Any other person who is wing on behalf of the demaaed and wfio has execoned a wren statement pursuant to Public HooM
Les Section 4201(7)_
least ALL THREE d me Assumed
9J I NJe hereby infirm than ins body W the dexa w aed does not nlein a b0lery, Memory pact, power Cell red oecnve implant.
nor`radioactive device and that any such materials were removed Prior o The essential of thin Autl dmu Farm. Failure W wore
Mesa Items Prior cremation may mull In harm b the cmnaory aM cmnaWq"flying.
9� Me affirm Mat Instructions have been given he MARK K PARISH
regarding the removal Manly Career property or other thing of value"Up any pawn signing straw or any many member of the
dmmwvvirMatobremvve. Pine other Orematorium
is not responsible for me removal of Personal dame from the Comparison fmm me remaoaof me mecrmed. Penonaf Mme lee In Me
conOUlmrorwiMNer ginSMilbedeaaoyed4ry ecmationl eeaeandCnnWMnNevadawrcnmeuon.
�1=1M'e hereby sumome Pine Mass Crematorium
to cmna4 Ne mmtm of me wersed. [w+avwb
FINAL DISPOSITION
T bpm�oneul(wse orrealva Me ue`mabm remain Wthe damawtlM1om Ne cremblory¢:
Name'. 4:r\s\w
Address 6% Ma. If, . Uubs.rlW1, W`112t1A Phone: IiN- (bA T4� Y1/(3
The aamated remama ofMttaeed all W disposed Wa.foloss
If for any reason Me damn named above does wheys pmawssron of Me cremabd remains,
Pine Vies Cremattenum iseulhor'¢emoglvepaeeeubnM
the remains he Came Camenton Funaternal Home Inc hydNoery
Pea, .,ww
in pawn or by registered mail.
Whllam 8. Ma hborm
w..ao...wr
DOA-1age-f(ReiW15) r Page 2 of
Authorization for Cremation and Disposition
pool Me Ammon
$ 1d INJe understand than if the remains am net dolmas within 120 delta otcnmman
Pine craw Crematorium may dispose of Me remeimm
anirsymeahle marine, such as Ey somenng. Mr*
CREMATION COWNUEWORN
An um to 0e used as a container per Me cremated remens No Non mr and from
and is described AS folWws:
INJe understand that ifthe um is We small W hold Me opens cremated rsmdll, an eddeMal rigid window may be uW far dNlvgy.
-OFF
1
w An um is not yet parchwed. INm onderaund that a no um Is grmMaeed or granyme pmnded
Pine Yew Cremawnum will plan the cremated romans in
a rigid sampwary container for delivery.
Too AU ortaetlon Form was provided by MARK K PARISH me describe at
Carleton Funeral Home Inc
09 Main St. P. O. Box S) Hutlsan Falls NY 12839
and is signed by Me aneral direcnw as vtlnness to its execution. wrc
IANe Fees reteivad a completed copy on this Awhodxarlon Form.
The penon(s)idanNMd1 below Islam the "non(s)In comma ord aposil who by Signing this AUMonnfion Form, atWegel
to the accuracy and complab ess of Me Information contained In this AUMwlsatlorr,Form and a,thodzas) Me foregoing.
Signed No 28 day W July . 20 20
Dearmis Wendell
1L �} I.Uz,�yax.ci
47 Corr.uxs. s
4) 1 Drive, Eli Sam NY 12020
asn..mrersi.
WITMPSB:
MARK K PARISH
Iz2Ln�
William B. Mattison
DOS-1890-t(Rev.all Page 3 of