Havens, Irma Elizabeth Pine View Cemetery & Crematorium
Quaker Road
Queensburyl NY 11664
(596) 745-4477 or (518) 745-4476
FUNERAL HOME: _
- - - -- RETURN TIME.
DATE & TIME REMAINS ARRIVED AT CREMATORY: ,-__�/-'LS-7p
NAME OF FUNERAL DIRECTOR OR REGRISTEREO RESIDENT DELIVERING REMAINS:
--- -/ 1tN .A✓ J�/ass id
NAME: -. CABER
�1—Y1rE1Y1.4L.__
TYPE OF CONTAINER: C_`Sr . I - -,Y[� �/j. J ��K
A A
PLACE OF DEATH: _ lgekA� 30"
ESTIMATED WEIGHT OF REMAINS 6 CONTAINER /G I(ICR,1e,1 Oz/6 S
PLACED IN HOLD:
PLACED IN REFRIGERATION: /aYSgr.
DATE OF CREMATION: l -29 - 4p -to
TIME STARTED: Z/9m TIME COMPLETED:
PLACED IN RETORT //$-flry1.,---
MOVED:
RETORT A IN WHICH REMAINS WERE CREMATED:
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREATION LOG SHALL 4 BE IN THE PERMANENT FILE OF THE CREMATORY.
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Authorization for Cremation and Disposition craw ,span..,».
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Dam: 7-29- ?ow Number: e74,
Cannel Name: Pine View,' Optimism"
Address: Quaker Road, Ouionsbury, New York 12804 Phone: 5181]45L7]
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Common Is demand out by placing Me remains of Me deceased and Me container holding Me remains into a
cremation cbamberw MW are subjected to intense reart and firms.TM Mat and f fey WM meanwMeaW
command everything except bone and metal,which are all Met will M left a rcmmaUn.
Following cr matron. Me crematory, fall eke reasonable etbtls to remove an of the remains and other maternal Rom
the cremation chamber, but some minimal dust and residue will likely be bll behind. The crematory will separate
ncidental and foreign matenal Rom the remains and the incidental and foreign Real fall be disposed of as
square by law. The cremated remains will be mechanically pulvenzed into small pieces and placed into a
designated container or urn. Cmmeted remains Smartly am pulverized Mall no single Mgmenl Is recogninMe
as skeletal Nsaw.
OPENING OF CONTAINER
The crematory may only open Me container holding Me ui cemaed human remains in limited (imumemncea, such
as to confirm the identify of the deceased or to ensure that no matenal is enclosed which might Injure employee or
damage crematory property. N human remains am delivered in a container which Isnot Usable fair cremall
such as a deremonml or Waal casket,the Formal will results that Me remains M movetl Into a suitable
coastal before N accepm Me rarrains. The opening of a container or the transfer or removal of remains will be
conducted before a witness and will he done In privacy, war dignify and respect
IDENTIFICATION OF DECEASED
Name of Deceased. Tli A)A✓ -v.S MNMlswus: Wrate u
LastlMavn Address'. wEJiSu
Prow of Death LJLi (cy
sex: DM MF B: ( ,y- DatemoeaM. 71jilichdi Eadmamdwalghc YO /65
Cameroon of estimated its or m which remalm sell the deliaered:
Carriages! Cardboaa Box with Plywood Smrmark Model V 30000
PERSON IN CONTROL OF DISPOSTDON
(PPansdanfa) in coal advantages,, full I ONE ofthe inasmuch
n r•• l amt We are Me designated agent of the cremated MoitrNW in a*it or women instrument executed
pursuant to PUNIc HesM Lew section 4201.
-ORT
- N^bhave no knowledge that the cremated exeanW a w*ihen instrument pursuant to Pubic HrWMLew
eecbn4201wocoilwnWningdlrecionsbrthediep bnofhaw Mrmmeineale (Cmtlnwdrrexpape)
ii �6✓ENS
W91eae41 ryw. orl) Parfet
I ant" am Me persons) having pnorlh under Public Healed taw section 4201 and have Me right to aoMonee
IXdnetlon M Me remains M Me deceased. My/Our M.Ewublp to the dare dl0«rollowa:
(sped from Me
lied diew)
Number-" Dwsperi an'. '1S,Ir xy.t
A person designated! in wtlting ouninsual Pudic Flesh taw motion 4201 (3),
x Tu sunivng spouse
L.The surviving domestic peMmc
(2:3ly surviving child agbteen years of age or Oder,
,L A surviving parent
a. A surviving Sming eigh en need of age or older;
S.A lawfully appointed guardian',
T.My persons)eighteen years of age or older entitled M share in Me satiate and who Were cosset In
raetherill to their dependent
S.A Mary appointed fiduciary of the estate',
9.A dose hand or relari who has executed a whiten statement Wrivant to Public Heath taw§4201(7):
10.A chief fiseal oftcer of a county era public admMislNar eppoiMetl WmwMfo Me Surtcgete's toad
Procedure Act
tits.My other cemon who is acme on behalf of the deceased and and has executed a added atalenrent
pursuant to Public HWth Lax§4201(7).
(pi ALL THREE of the blkxirp)
AN Imp hereby affirm Ma the body of Me Medical does not conMM a batery, battery pack, power cell,
adlosi implant, or redicarchve device and Mat any such nalenels were removed pnor b Me execution MMw
Authonimpon Form. Failure b nmo'n Maine Items glwb counsel may rout in lurm to tw rnmalay ON
mnabry pemon«l.
/QN Ovae herebyaffirm MetinsWcdonsba« Been given btuny✓awm.+I Sasr Pahes lliLio regeNiy
the removal of any Normal propel or either thing of wave which any gammon signing below or any family member of Ms
dese«dwish«toprmerve. er m r�,nw) s not resWnside for
moral of personal items from the container or from Me remalos of the deceased. Pemmul hums Nit In ere coral or
with Me Mnelm an W destroyed by Me cremation propose and cannot lh narrowed after cremation.
,&)4 IMRh rebyauthoRisrowreroyrema) P V C t o tocramaw and,
remains mtlu sec«sea.
FINAL DISPOSITION
The peuon autlwneed m rewlve ter cre remains of Me des fmm Me aemaerrya
Name: P
Address: 11 L S W b PINcNA5191 ]BLB303
The uematN remains of avowed will be disposed of as talons.
Realm M hardly b be amtlea
If for any reason Ms person named above does not dice posceeeion of me cmma remains.
w+�miwr n C s waoadd M give possession of the remains In
rnmvx,uromy Baker Furefal Hwn by didial ry In person or by registered mail
ooc.rwuJ iRw DIM) A,.ae.,, e Pril
IW 1me knowing)
IAk undemut nd Nat pthe remains are pP[sfelmed vdNin 120 days ticremedon,
Iwmroy m.m) Pine Vlew Cremabry may dlsyre of the reruns In an illBNmde manner,
such as by ScaMny.
CREWTIONC AINEMM
OnAiillONE fable Mbwng)
00 An um M be asset as a container fix the cremated remains has Seen purchased horn
Baker Funeral Hcme and is described as f icive:
IM@ undersnM that ONe um u ad artall to h0ld file mrore overreact dealns, an additpnal ngn container may to used
for delivery.
AR-
M um has not yet Been purchased IAIe untlersbnd Mat g no um Is purchasen or ONerais i provided
rea++rsvnenet P-rre V'ew Cremalory will place the crema rd remains in a had lemparary
comanerardellvery.
This Augwrvntim Form was andidM by lam�wtirmre++l
vas ecuted atMxrvnmemrm� F
pivwuno.i..mre t 11 L Shoe N Y 12 end is signed by dale fureral dire
as witness to iR execution.
IMC have receiver a completed copy of this Autnodzator Form.
The personnel) identified bebw all the paraenta) In cwdml of disposition, who by signing this Authorization
F°mh azbaRs)ad to accYracy and dompNbnaP °f the Infwmatbn comalnatl in this Authorization Form and
authoraNa)the foregone.
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