Montgomery, Kenneth P. Pine View Cemetery L Crematorium
Quaker Road
Queensburyl NY 12804
(5(Q1J8) 745-4477 or (518) 745-4476
FUNERAL HOME:
-- -- -----_.—_ — _ RETURN TIME: 46HL
DATE & TIME REMAINS ARRIVED AT CREMATORY: ?-29-Ze7d
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NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
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TYPE OF CONTAINER: /ii✓ Lam/ / T
PLACE OF DEATH;
ESTIMATED WEIGHT OF REMAINS S CONTAINER_ /7r/A5 $4IBA /Sd/jf
PLACED IN HOLD:
PLACED IN REFRIGERATION: /fyQ�ry
DATE OF CREMATION: R
TIME STARTED: /4 (V OA TIME COMPLETED: _2 y�///N+I
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OLACEO IN RETORT: ___MOVED:
RETORT MIN WHICH REMAINS WERE CREMATED: $ 2� YO PA.(
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE "AN AS HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SHALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
Authorization for Cremation and Disposition
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This Ar orizaaon FormmM bs mala/Nad slap pr to its Wl of rerll Ms ftrprmv .
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Cl Mory Name: Pine YewcmmMON
Addrms. Quaker Road, Oueensbury, New York 12 Phone: 5181)45-047]
CREMATION 15 AN IRREVERSIBLE AND FINAL PROCESS.
Cremation is carried out by placing the remains of the deceased and the container holding the remains Into a
cremation chamber where they arense subjected to interim heatand flame.The Mat and flame MEIndnernto add m Consue
eveMhinge home And meral,what are all that will be li a%er Draughts.
Fol[owl ngcreiation, the namedry will take reasonable efforts to rem ove a n of the remains and other material from the
cremation chamber, but some minimal dust and residue will likely be kh behind.The crematory will separate Incidental and
foreign material from the remains and the incidental and foreign material will be disposed of as required by law.The
cremated remains will he mechanically pulverized into small pieces and placed into a designated container or urn. Cremated
mains generally are pigvMzed uW no Yroe hagment B as skeMal game.
OPENING OF CONTAINER
TM crematory may only open the contamer holding theun-cremated human remains In nmlted circumstances, such as to
confirm the identify of the deceased or to ensure that no material a enclosed which might Injure employees or damage
crenotorypnoonift- If human remansa a released Ina containervehich Is that sultedefa cmmntlan such as asmhRdnh l or
rental asked,the wemMory will require that the remains be moved Into suitable container before B accepts the remains. The
opening of a container or the transfer or removal of remains will be conducted before a witness and will be done in privacy,
with dignity and respect.
IDENTIFICATION OF DECEASED
Name of OemeaBM-. Krf N/HJJT"/f A / {0.CJ�r a[IN 6[lLu Mantal Status: 1� 0 .
tall Known Address: / a (,p �,yy \ /[/SOT 0'/ U' g Fort, AV 124
Place of Death vLL'JI — I 1_
Sea: kM OF PER: il' DOB: y DaIeINOBath: 7 Z Z,e ESRmkPw Weigm: / 7J 4
Description of fasket/container in which remains will be delivered:
Corrugated Cardboard Bog with Plywood Stainless Model R 388M
PERSON IN CONTROL OF DISPOS71ON
(Personjs) In control of disposition, initial ONE of the following)
I am/We are Me designated agent of the deceased designated in a will or written instrument executed pursuant to Public
Health law section 4301.
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f I/We have no knowledge that the deceased executed a argues Inrtrumem pursuant to Public Health law woman 4301 or
will containing direttions for the disposition of his or her remains and(Conflnued next page)
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I am/we are the perwnts) having priority under Public Health law section 4201 and haw the right to surmise cremation
of the remains of the deceased. My/Our reMlansNp to Me domi b as blMINS!
(natimmm Mendowaw)
Number. E�Oeacnption: SfS �GrC_
A person designaktl in voting; pursuant to Public Health Law Paton 4201 (3);
1 The surviving spouse;
2a.The surviving domestic partner',
3.. Any surviving child eghteen years ofage or older
a. AsurviviNparl
AA i tt 5 b1 g ghteen of age or older
S. A lawfully appointed guardian,
T. Any person(s)eighteen years of age or older entitled to share in Me estate and who same closest in
relationship to the deceased;
B. A duly appointed fidudary "a estate;
g. A dose friend or relative who has executed a which statement Fursuahw Public Haar taw§d]01(7);
10. Achieffiscalof rafamuntyora WblicadminisbaMrappointedpursuantMMe Suvogate'sCud
Procedure Aril
IW.Any omen person Me is acting on behalf of the deceased and who has lowered! a written statement pursuant
w Public Health Law§4201(7).
(flirt eAU THREE of Mefolbwing)
1/We hereby affirm that the body of the deco sed does net concern a battery, battery pack, power tell,radioactive
implant or radioactive device and that any such materials were removed prior to the execution of this A.Moruation Form.
Fagurewremovet Restprigwsfemalonm result Inl rmla MecremMa aMaemrtorypermnmi.
C5l100! I/We hereby affum that nstrutions have been even to r/wtiwraarcruw.n Smrr Bokera10159 ryaNingthe
removal M any personal proper or either hing of value which any person signing below or any family member of Me dissected
wishes to cremrve. (ammm.) Pine View Cenci is not responsible for removal of personal
items from the container or from the remains of the deceased. Pere nal items left In Me mntafter or wits Me remains will be
destroyed by the cremation process and cannot be removed after committee.
C.Er/ lMe hereby authorize imi to merger the remains of
the Marersed.
FINALVISPOSInoH
The person authonzed to reserve the cremated remains of Me assumed from Me crematory is:
Name'. Baker Funeral Home Personnel
Address: llUfaveMS Q tau Phone 15181 701-03 0 3
The cromm ] remains of deceased will be disposed of gas follows
Realm to family robe decided
H fur any reason Me person named above tices net take possessed W Me cremated remabre,
loeaWOYna+a1 Plne Yew Crematmv is ashamed To give possession of the remains
grind saw Baker Funeral Nom by delivery in person or by registered mail.
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p r l Ne understand Mat if Me remains are x4alpiptlwiMln 120 days; of cremai
raenwwvawl Pine y Crematory may chances of Me remains in an instrievable mannerr
such as by scathing.
CREMATION CONTAINERA/RN
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—An um M W usetl as a container for Me cremated remains has been Wrchased frohn Baker
Funeral Home and is reservist as follows
Me understand Mat dMe um a too small M hop Me entire cremated remains, an additional mild container may W used
for delivery.
-OR-
&AAn urn has not yet been purchased. We understand Met Q ng um is purchased or otherwise provided roei
nmmel Pine Yew Cremabry vd11 plow the cremated remains in a digit Mmnmary
oontainer for delivery.
This Authorization Form was provided by l(wrvwweaewnusl -/1+'u+ 3fYY erL
was exewted at ai Baker Funeral Home
nv�rma.sa.vl 11 tafavette Street Oueenshury New YOM 12ag6 and a signed by Me funeral director
as witness M its exewaon.
IWe have reconnect a completed copy of this Authontroon Form.
The persons)informed below iarere Me persons) in mnbd o/dspo&don, wfio by sn ing has AUMorizafron
Form, aftest(a) o, Me accuracy and completeness ofthe uslonrleffoo conta41sd in this Authorization Form and
auMorize(s) the foraffoling.
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