Raynor, Alice (2) Pme View Cemetery & Crematorium
Quaker Road
Queensburyl NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME:
__-Artz,-__. . ._—_.._._.. RETURN TIME:
DATE A TIME REMAINS ARRIVED AT CREMATORY; _ .NAME OF FUNERAL DIRECTOR OR REGRISTEREO RESIDENT DELIVERING REfrIg1NS.
NAME: _„____ yyaaLI —
.��
TYPE OF CONTAINER:
--..�I•i -RdI1 A ..n hE�dp_�EtDB
PLACE OF DEATH:
ESTIMATED WEIGHT OF REMAINS B CONTAINER__
PLACED IN HOLD:
PLACED IN REFRIGERATION: ____
DATE OF CREMATION:
TIM! STARTED: 7�It'AH TIME COMPLETED: Y.R
PLACED IN RETORT: __MOVED: __ a,:21 y:oy'gn
RETORT # IN WHICH REMAINS WERE CREMATED: (�pw
DET
LED
FROM
TIME
OF AC FOR DELAY IF REMAINS WERE CREMATED MORE THAN p3 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE THE CREMATION LOG SHALL BE RETAINED IN THE reRMANENT Flt[ OF THE CREMATOR
Autjonzation !or Cremation and Dis osition NV5p°°""neNo1sea
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1TMAutltwhafbn Farrrr mYlfM Cou~ dalgnedprl daft yof remains; Ior ertnagan.
Date: 8151>a Number: 88�
Crematory Name: PineVenCrametorr
Address: Quaker Road, Queensbury, New Yolk 12804 Flame 1513179 77
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation is carried Out by plating the remains N Me demanded and Me container holding the remains into a
cremation chamberwhere they are subjected t0 intense heat and flame.The Not and flame will incinerate and
consume everything except bona and metal, which are all that will be left after cremation.
Following cremation, the crematory will take reasonable efforts to remove an Mthe remains and other material from
tiro cremation chamber, but some minimal dust and reedue a II likely be IeRbehind The crematory wilt separate
incidental and foreign material horn the remains and the Incidental and foreign material will be disposed of as
repaired by few. The cremated remains will be mechanically pulverized into small pieces and placed into a
designated container or um. Cremated remalns generally are pulverized until no single fragment Is recognizable
s skeiatel tlesus.
OPENING OF CONTAINER
The crematory may only open the container holding the un mmated human remains in limited circumstances, such
as to confirm Me Identify of the deceased or to ensure that no material is enclosed which might Injure employees or
damage crematory property. N human remains are delivered In a container which Is not suitable for cremation
such as a ceremonial or rental casket, Me crematory will require that the remains be moved Into a suitable
container before N accepts Me remains. The opening of a container or the imnsm,or removal Of remains "it be
conducted before a witness and will De done in privacy, with dignity and respect.
IDENTIFICATION OF DECEASED ��''� "" ,,�!
Named Oeceasad r tInac Ma Status:
Lest Known AOEreas: 27 W AUC3L
11 ed (I .m�Vx l III nxoy
Place of Death: Glens FIB ♦W n AF ' I
Sea: DM pEF Age: 19 Doe: 1� ��� 197 -1 oareaomM: 31 , 1202D EetimmedwegM:��_
Description of caskegcoNeint in which remains will be delivered
COrtugeted Cardbomtl Box with Plywood Slarmant MGHeI a Made
PERSON IN CONTROL OF DISPOSITION
(Peearrib in control Ofdispositi iirdi ONE ofthe fdbwamJ
a"We are Me designated agent of the deceased designted in a all or wri ten instrument executed
summon W Public Health Law section 4201.
R-
pAb have n0 knowledge Mat the deceased exaGdad a wrlNBn instrument PuAOOnt t0 Public Holum t 8w
9201 or a will containing direction for Me disposition Of his Or her remains and (Canonised rm#pp)
A tta nGr
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I amtwe are the persons) having promy under Public HeaIM Law section 4201 and have the right to authorize
cremation of the remains of Me tlecerees UpOur relationship to the deceased is as follows:
durum ream the lid 0 i 1
Number Descdpdon'. SST. !_ +. — 12W
A person designated in wonting Williams to Public Hearth Law headed 4201 (3),
a. The surviving spouse:
L.The surviving domestic partner,
3. Any surviving child elghdeen years of age or oki
a. A survivirg parent,
5. A surviving sibling eighteen years of age or older;
II8.�. p A lawfully apohHed guaNlan;
k/MI, person(s) elgme er years of age or older entitled to share in the estate and who some closest in
relationship to Me benefited.
8.A duly appointed fiduciary of Me estate;
8.A close friend or release who has emended a sudden sta M pursuant to Public Health Law§4201(7);
10. A chief l scal officer of a county or a public administrator appointed pursuars W Me Surrogate's Court
Procedure Ad;
1Oa. My other person who Is acting on behalf d Me tendered and vitro has featured a women statement
pursuant to Public Health Law§6201(7).
LL iNFEE MMa rolbwirgJ
Wye heresy aMrm Mat Me hotly of the deceared does not contain a batery, battery pack, power well,
dive implant, or radioacdve device and that any such materials were removed poor to Me execution of this
r uthmrsation Form. Failure to remove Mesa Hems priorW comrades may result In harm to the community and
Wry personal.
IAVehembyafirmthatinsdu mshasebeengiventoft .id.ee•M ) Stan9eker #10158 regarding
oval of any personal property mother thing M value which any person signing below ormwfi mily member of Me
ce teedwishes to preserve. smmemy,wre) P'neyiew Cremaery is nor responsible for
removal of personal hems form Me container or from the remains of Me deceased. Personal Hwm left In Me container or
yyph a remains will her tl Mroyed by We cremation process and cannot a mffl dafter consent
IJ MsharebyaNhorzd(o.,mm ,n ) Pine View Chemistry to cremate the
rlt sod Me deceased.
FINALOISPOSRION
The person authoomd to receive the cremated remains of the deceased from the crematory is'.
Name. Baker Funeral Home Personnel
Address: 11 Lafavelle glass. Oueensbury New Yoh 12804 Phone(08) 781-M3 _
The cremated remains of derh a sal will be disposed of as follows:
Rehm to family to be decided
If for any lesson Me person named above does not take posseral of Me cremered remains,
(c,"'i•mw) Pire Yew Crematory is authorized M give possession of Me remains to
rNMWhi'm by delivery in Person or by registered mail.
ttat per
DJSraaHJ lRw.amen Nnp05 Psi
INJe unaerslaM toot if the remains are opt tlannetl whin 120 days of crematow,
.malmay Marine older remains in an maintainable manner
ch as by scethving.
CREMATION CON AINERAIRN
(ntla ONEofthetdrewsid)
An um to be uses as a container for the cremated remains has been purchased from
Baker Funeral Home and is described as follows:
for d dnd t118t Rule Ilm le too ema1 to bola th0 a11pR GGmated (tY11dIM, an additional right container may bB used
for density
.
An um has not yet been purchased. IWer unaerstend Nat R no um is purchased or otherwise provided
r I Pks Vlaw C will place Me cremated remains in a dg!t temporary
comainer MrtlelNery.
This Authorization Form was Imaitet by�mn nwmi Start Baker#10159
was executed at inw.nN.l Baker Funeral Homa
Ia�a�wacrre Hywl 11 LafeveRe StreetO ebu N YIk 12BO3 and is signed by MG funeral director
as witness to its execution.
[We have received a complefetl copy of this Authorization Farm.
The aerson(s) Identified below Were the person(s) in Control of dlapcsition, who by signing Mis Authorization
Farm,anestlsl to Me accuracy and completeness of the Information contained in this Authorization Form and
auMorize(s)the foregoing.
Signedthb day of Zp2z'
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WITNESS: `� �
Starr Baker
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Funeral Homo Reg. Wl130
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