Jackere, Alan Leonard Pine View Cemetery & Crematorium
Quaker Road
Queensburyl NY 12804
(516) 745-4477 or (518) 745-4476
PUNERAL HOME: �'�� . /i _- RETURN TIME: I1OYI�i
DATE & TIME REMAINS ARRIVED AT CREMATORY: ,_ ,
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS-
NAME: REMAIN—S:_
NAME:
_.— (�'L4dnon�io.P /t✓rt __<wseR �7�L_'
TYPE OF CONTAINER: `n�snc/
PLACE OF DEATH: _�_ 0./� S
ESTIMATED WEIGHT OF REMAINS S CONTAINER__ _ /SD /!&/T 3' ✓ .1 L3316S
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION: 7,29,2820
TIME STARTED: loly?gm TIME COMPLETED: _ IZYQOY/1
PLACED IN RETORT: IOS3' r�i= —_MOVED: ZrSrdF+'I
RETORT Y IN WHICH REMAINS WERE CREMATION
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 PERMANENT FILE OF THE CREMATORY.
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✓ ' NAEWYORK Division of °^A61 NOFF �„
IN°P°OR.° Cemeteries AarwnA,,^w
Farm NY12231-0001
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Authorization for Cremation and Disposition
TNIs AUNwLetlon Firm m nd Mmarginal and aprea pia to Mllwry annu m Ida[mmatlon
DB1e'.JULY IR.AXN NImM[ 1034@5 _SL7Y
Creamery Name. PINE NEW CRELL5TORIUM
OUNNER ROAD OUEENSBURY, NY 12604 Phea 5167954477
CREMATION IS AN MREVEMS E AND FINAL PROCESS.
Comalian is memo cut 4 piecing Me remain of demand and his,normal MMiytlk n Om into eae'nMkA Neater Mren
May arem Ali May lo'mlmse affair
creme. TM Mgvnd Mmewill N[Irwaemd mneunNwvryNNgeswgboro vrW meael,
wlikM1 vreell WtwIIIMhXaMr[nmce rea
Fender, uamm inMe sured dust
dkueachI Eleal aft Al reamhall elm remai seemed
ma[eruam Peoemall
the MaLsandtminima Ulan Unaaenm vAllmlied paFindw ae 4vay eepamNimdm aMwilMmadmanhum
paten mito sliel same and
aSealrallLe dupmdMcan, C Mtry lax. ma frmmalyam MulMn Ee meMt of
pulresfm mm small wawa Una wawa inro a ahagnmd mo,.timraum. Cmeed renulre gsnarWlr.m pulwNW uMl m
amglarmenemk re[mgnissoe as akaMMlesw.
OPENING OF THE COMA NER
The immunity may only raw Me mama,M1olairg,M unuemalM human remain in limited owm&enma sits As to=l Pe
denary of Me recall ormeNure Met n ,mm its seamed oniT might injure employees mdamage the deal pi49rll n
human mm im art delimit N a mnmLerwlMm is,nobmYele for nemauon such as=arem rniq damned Ml its
mremgnrywln manila 111attlN nannilM Ea madIMmaamMOla wnmmar Carore haaulam Its remain. Ttemensi ae
mainerwthetramrermrefu l Mremmm Wu W anauctea Mee a wiaess and will w done in prirany wiledWgaMmeTed.
IDENTIFICATION OF DECEASm
Name of Pomeadl AIAN LEdN JACIffAE Marie) 5dwe MPRRIED
Izst Hnown 0A 1307EA5T2eTHBTREETTUI54OgAH JYrN9
Plead of Usage 354 PAUSADES NO BMNT LV'.E.NY ll
Se.: OM ❑F Age. 76 DOB. 11/01/1944 aewa 07/l712020 EMmM "k 150
Deawiptkn of raskMOMeiMr In same remains wil M addressed,
FLORENCE CASKET COMPANY/CREMATION CONTAINER/ CARBOARD/FIBERBOARD
PERSC N CONTROL OF DIBPOBITION
(FMmISJ In cndd adumeal all ONE 0 Me bWavq)
I amble am NemIV"Ague of tlm ethanol da4gMM in a Mr a YRMen i ¢ mend dewM Wmuml W Public
Hewlett Raw Same 441.
oMr2noMhemodNan Ve he or hreamAeand hand Me ow,
Pualk Heats lox health
era
MIImn 4WI M.,ace,f for the A somemhomdo remains and LNe ueIts cer as Nrag piwiy WPuatic Health Law
Sedion4201 aM Isere Ne rghllo auMorue comedy car Me mme'vna M1Mmmaaea. MYrOW mNBmmllipaodm demautl Is as
blkww:
ALAN LEONARD JACKERE
DOS-hm,fMw hot Page 1 of 3
Authorization for Cremation and Disposition
Harmful 2 me(4Diddep)
NumGer 2 Dpaippon: 8POU3ETMFE
1. A pernown oesWaW,n al WrsneM W Pool XSYN Low Section 0201(3):
2 111M aarrel sewer,
U. The wMuing Nepal prommer
]. Any wrvning died"boom year¢of age or oNer
A Aporming (gryM.
i A pumping abllng suffered years of No or under',
8. AISMUIryappolmer prompt,
T. Auy pyMn(e)sghteeri years W age a older mMpp W share in Me Mend well and spare copper In relel ip ad the hxened:
8, AUYIi appointed fi ail W Has atoll.
S. Adead Mend by royal corm body onal a written atalemeW pursuant to Pul Health Law Salim OR%(])I
10. Achilfall OMWr Of a county of a public wonderful amended pursuant M the Sul s Com Procedure M:
I An call Mmodel and is wrong On behalf of Me deaeeed add man has moral a wdben statement purauent to Public Health
LL THR Em Mew
DVy rgreyy amnn and the bNJ M Me dewed aces not banned a bydMy, MYary posse poor del. ratio eimPEwt.
w Md"*red"AaMOWaWe mah NsmreremavedpdaMMsm imO(MisANM1a Fom. FallunWmnova
Lt/w�e(Name eager m on ma W Cnady mum in harm W they m cn deb model prem and modeml.
_evil win Net manufactures hew been given a MAAES P. McOERMOTT mmcmamwm
orr
real g the mmoval of my perna lMailp W,x Man covY.e~yry arpn signing below of am M1mAy m WMtln
consul wanes to preanve. PINE VIEW CREM4TORIUM
is but responsible for Me mancese Of personal Verna Man tM comb¢ r or M1Om to means of Me decreased ftmml Name left In Na
S ho ar or x Me owners will be dNYeyad W the a Oranrallan prOONa rm mrM b reWevNfirm Cf UM.
customer
M'pa Mnb/eedlwrize PINE VIEW CREIMTORIUM needed.
by CNr110e tie remalre WMedamwtl.
(finalGern10NAL)
Idea Nnby arMOdn Me named( ldhaWu W provide fM dNlvery a and m=Ow by M aX W
mandatory, If deenrM rece q M Me cpinlM M ae amend added.and a and M form a movMa theCoerval reand
mandatory,
such arm OarmNry.
FINAL DISFOSnwN
They pmstn aWmsed to receive Mea ended remeim MMe disposal fiml tie cheater I9
Name: JAMES P. M ERMOTT OR EMPLOYEE
Address: B PINE ST.CHESTERTOW$NY 12817 Rcne'. 51SAg42011
Tee¢senora ro-aim p(demepd wtn ro deemed M.rdw.M:
If KKanY rmwn Me peraMrumad edee Mmndake pmsmaM arms aemebd lglWra,
PINE VIEW CREMATORIUM s accursed to grvs rodual hw Of
M ie destroyed; BPRTONMCOERMOTi FUNEgby-NERK HoMl by dMrvery
in pMsm by by reglMerad mad v.rw..gILN LEONARD, MRE
Phenomenon
00S19g6f grow 0MR0) Page2M9
Authorizption for Cremation and Disposition
lni M Initials/ Vital understand tNM if Me remains we not claimed Main 120 MRIS NaemM
xr
PINE NEW CREMATORIUM may cispun My Man nonelns In
,�
an mandam mse Moral soon as by vent
CR TION CONTAMERNRN
✓ !Y�\ Anum to be used as mOar9 W MCrYnBletl remmns has Risen Pornla`ed Ran�J ter/ ®�®�
Yanddlod—escrmedasblldn: ✓k*✓
INh uMsatand that it Pn um is bon small b Mtl Me mNe baseness reason, an ankhm"I Vad canner may ne used MtlNXxy.
OR-
M un 4 rA yes WrtluM. IMYUMarebMmetif m an b Wrtls+sad adtax»e Pmvlded
PINENEW CREMATORIUM will place the cremate] remains In
a i temgx mnlatrer br dMery. �nuwum
This AWwrlse Form was MWNd by JAMES P. M Dmmo
mya� wsys exaculat
SARTON-MiDERMOTI FUNERAL HOME,INC.
wm�
8 PINE ST CXE5IERTWM.NY 12817
pi.vre..wma
am Is street by me Rmeral arw««weeds to tM a ammdn.
Wde mare reraHetl a comlNeted copy M NIS ArMvtrauon Fmm.
Than Personals)WandflW Rake,Wlte pncenal in Contract M dbpesl hi by Nat WAWMiaatlon Farm,&s Jsl
Is Me accurary and compIMMMF Mtle N(wm wW Ml M Mile r1WMNadm FOrrrr YldaWorKalcl she lorpail
SlprrM MIN
dW d JU1LY
HARO�AN�N I4CHERE J)IVSOH � 1l Nl.l1L. (PnR
do
1207EAST2dThI STREETTUL3q OHIAHOMA �YOOR
�m
Mean
Ads,
WITNESS: /
ft—,JAMES P. MER O� _ . �� ,
133W
�� P1AN lEOWAO AACHERE
O061&A-f(Rev. W/101 Pal