Waterston, Ernest J.B Pine View Cemetery & Crematorium
Quaker Road
Queensburyl NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL NOME: _
' ---- _. RETURN TIME: Il.y-N .i
DATE 8 TIME REMAINS ARRIVED AT CREMATORY:
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
.C� a —...
R J`�I
CASE 9 .
TYPE OF CONTAINER;
I
PLACE OF DEATH:
ul/
ESTIMATED WEIGHT OF REMAINS B CONTAINER_ /'SD /G.$
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION: '7-2V20Tp
TIME STARTED: _090SM TIMECOMPLETED: /0570fm
PLACED IN RETORT: VIIOSp M __MOVED: _fO 'LSgT.1
RETORT R IN WHICH REMAINS WERE CREMATED: _�a P/ K
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOS SNAIL BE RETA Erv� Dery THE PERMANENT FILE OF THE CREMATORY.
Ink Sin•
51 rORK pIVI510Il Of D•vmm•mastab
STRTEOF DM IONORCFMETERIES
OPPORTUNITY. Cemeteries
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Authorlutlon for Cremation and Disposition
This AuNmrlufian Form must W complNea and Signed prior to aeliveN pythoness rot commands.
Dab: O]Y28/2020 Number: e73
Chemewy Name: Pine VIM Cappell y
Aartss: 21 Quaker M, QDeen$Wry NY 12804 Phone: S/>f7lf ��
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremaom is Owned Out by PWW the remeim of the deceased end nit NnWner Mldmg TO mnalm Into a Gemabm chmnber MMre
th"of augeaad W mbme heat and name. The heart eM gamewill membraneand consume awrphing exddw bon•and metal,
whim ere all Met will be left After CMm Lion.
Following command, the amatory will lake reasonable eflods to remove all of me remains and Or material from the cremation
chamber, bur some minimal dune antl feel we likely be Ian behind. no crem•m y Will parents Incidental and foreign material"in
me remains add McIm®ra land mouth mabrial will be disgyed M as required dylaw. The constructed remains coil be mecmnlolly
WMriz•d Into small pieces add placed add a designated mnWmr Or um. Cr W remains gem211y an pulwrbed unfit no
single bgmert N xoanlaabk as skAM l Means
OPENING OF WE CONTAI NER
The aemalory may only open the container hoeing the uncmmeW named remains In limited u¢umstanres, such As to Wnfom the
khmmy of me tlewased Or to ensue,that no material Is enlwad wh'ich might injure employees or damage the crematory pripent If
human remains an delivered in a mnti iter Mich he not suitable hemorrhaged such ae ceremonial material u•ket.Su
channel sell require that the remains by moved Into a suitable together before it accepts Me remains. The dpenirq Ma
poobiner or the transfer or removal of remount win be concurred Will a witness and will be done in privady,with salary and reaped.
IOENTIFICATNIN OF DECEASED
Name Of@ceased: Ernest B. Waterston maMal Stases: Manned
mat Known Andreas: PQ Box 124. 58 State Route 28N, NO Creek, NY 12853
piece of Dead: Glens Falls Hospital, 102 Park Street, Glens Falls, NY 12801
sex: ®M OF Aga: 84 DOB'. 01/1511936 DMemD , 07/27/2020 paumered "gm: 150
Desmlpool of cmkeNC iner in which remains will he anwras
Florence Casket clause container
PERSON IN CONTROL OF O BPDS TIDN
(Fbrears)in deal man!ME WIa Mbwrgl
I emar we the deelgnaled agent of me dwzas•d designated In a sell or vnitbn insWmem exacted pursuandto Public
HeW h Law Sx4on 4201.
xINie rave no knowledge that the tlewazed executed a written instrument pumueM to Pubs¢Health Law SMIon 4201 ora
will containing directions f x the disposition of his or her remains and IM9 are me ceramics avlrg parry under Public Heald Law
Settling 4201 and have the right 10 aumchze cremation Of the remaine M me dreaded WMur nhatica 1p to de stressed Is as
folbwa:
Ernest J.B. Waterston
Dp l Sail(Rev_0420) Page of
Authorization for Cremation and Disposition
pnmd torn ma art bemw)
Number Hmmtcn'.SurviNnD Child
L A person downgraded In vessel pursuant to PUNic Health Law Semon 4201(3)',
3. The sural spouse',
]a. The mrvwing domeatk mMv',
3. Any among cmd egMeen years of sage or taker;
0. Asunt parent
S. A surviving sibling eighteen years of age or older.
9. A lawfully appointed guardian',
e. Aduty epwnted nduaary eofwaf theastate or older entitbd to share in tat Bathe and who Ware Obeeet in RationMip to the deceased,
9. A close fir or rell who hen executed a written abtament star t to Public Heats Law Season 0201(7)',
10. A Ubl fiscal officer 0 a county or a public administrator morn ponusaM R me Surmgale a Court Procedure Atl;
tall Pry Omer person who is acting on behalf of the deceased a no who has execued a wd0en atatemmtl Panama to Public Heats
Lee aealm 4201pry
(byyayL THREE of the mmiscr I
Iowa rereby al Met the met or the aereaaad does rim roman a beery, banary pea, Power cll.raaeaw.e implam,
or radi0al dace and that arty such modest were removed man to the uewYm Of this Au zatlan Form. Failurewmmve
prior he cremaaon mry mull In ham to Me crematory and cr tat personnel.
Vase affirm mat inMMdl have been glass to Dann Alleourader
regarding the removal Of any personal property Or other thins of waste which any person sgning below Or any family n WofMe
Model whereas to preserve. Pine View Crematory
is not refusal forme removal acemnal rcemafrom Me coeditor ofrom the remains of the dwee ed. PersonaliMmsiNinthe
yypytdyiI or wnh the remairm win be ddethdyed by the m m ria minion pdes a carted be rmxw etl after chimatem
f /' "Irvae hereby authorize Pine Vier Crematory
shi Mostro cremeft the remalm or the deemed.
(al Doti
LMn hereby authorise the named funrral director to The itl r far delivery to and cremation by an abmM
tary, It deam ekee camel sum etl necessary In the opinion of the funeral director, and to amend this Man to p the aM
.mudame meuch anernato cmmmory.
FINAL DISPOSITION
The Memo awmdaed to rerelver Me amended realm male described from Me mmMnry is,
Name:Alexander-Baker Funeral Home, David Alexander
Address. 3W9 Main Street, Warrensburg NV 128M Phone: (519) 623.2055
The amounted .maim of dareamb will be amassed me halms:
Rehm to family
nmr am maw now wmn "mad above dead not rase pomsiasm of Me crernatea means.
Pine View Crematory is aunrMzad to am wsmmMm
the means Alexander-Baker Funeral Home by dalwasy
In person Or by miss and mail Ernest J.B. Waterston
DOS-1 B96f 1Nev. 0420) Page 2 Of
Authorization for Cremation and Disposition
m min al
IfwewdemMnd that it the remain She nor aaimee corns tzo a.ya arRmnagan,
Pirte Yew Crematory may dispose of Me remaden in
no..wc..wmi
and Jreveple menret,Such ubysutlenrg.
CREIMTI(ANMNTAMERURN
iddidd ONE of the/albwrng)
Alxander-Baker Funeral
An um to bete J as a container for Me uemak!«meate has M purchased hpn u.....e
and IS described as follows'
Ii understand that if the um Is too=911to hold the Sure crescent mandate an Scattered no commer my be used Sir lNivety.
-0A-
A�—AnumisMtyetpuchasida l leuntemlaWN Hnaun WrcMsalora omwpmnded
Pine View Crematory Wll place Me Cremated remains in
a role temporary contends Mr cedlrery.
This AUMornfron Forma was provldal by David Alexander was emMed at
Alexander-Baker Funeral Home
I�t
3809 Mein Street, Warrensburg, NY 12885
real is sinned"a fuMnl director as amasses Its GeCuti0n��W
lMe have received a commled may of thla Authorization Fom.
The prraonts) IderNfed below Were the per lel In control of Mssanuttn,who W sianina this Arduousness Fom,aXaetts)
to Me accuracy and compltlenns ofthe IMomnder Contalred In Of$AUMmzadw Pam and autlwinuls)the tonightng.
Signed MN IBth day of JuIY , xo /
Pamela L. Weleratbn
8035 Dan Bark Drive, North Ch"WffiieM, VA 23235
W NMS:
David Alexander
f 0034
Emast J.B. Waterston
w.wamm
Min-tied{(Rev. 04l20) Patti