Osborn, James R. (2) Pine View Cemetery & Crematorium
Quaker Road
Queensberyl NY 12804
(518) 745-4477 or (518) 745.4476
FUNERAL NOAuH
RETURN TIME
DATE & TIME REMAINS ARRIVED AT CREMATORY:
NAME OF FUNERAL DIRECTOR OR REGRISTER[O RESIDENT DELIVERING—REMAINS—:
NAME:
C
^ ggE IF
TYPE OF CONTAINER `�r(l//.aP k a /a / =
PLACE OF DEATH; ��L'zg41n_CLa SS .Z�� A,6'TF z/ 1 •___ESTIMATED WEIGHT OF REMAINS 8 CONTgINER__I75�5� ['jZ �}
PLACED IN HOLD: --
fhl _
PLACED IN REFRIGERATION: _
DATE OF CREMATION: _7'�h4ozr/
TIME STARTED: TIME COMPLETEO:
PLACED IN RETORT:
-L Fh_..__MOVED' /Lsm
RETORT 4IN WHICH REMAINS WERE CREMATED:
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SHALL BE RETAHNE. m THE PERMANENT FILE OF THE CREMATORY.
per
_. OMOsm Depee
NEWWJRK i)IVIs1011 Of DNISION OF CaMUMNES
STFX Ole mirrew .Roza
STAI Sa ulm. Wawnanntivenue
Cemeteries AINne,W 1223udgol
�a as
Authorization for Cremation and Disposition
That AuftHzN n Form must be completed and signed prior to eefrvery of remains
far cremetlon.
Data: W/3012020 Numberr. y8
Cheerlessly Name. PIDe VI¢W Cren10t0 _
Marsall 21 Quaker Rd DeanSW NY 128M Phone 5 �Q7H54Y]�
CREIMTION IS AN IRREVERSIBLE AND FINAL PROCESS.
Champion by umed Or by peens lee remains athe deceased and lee menleiner holding Me remains into a crema ch chamber where
Ihry are sublei vaIntense heal and flame. The heal and flame will Incinerate and c 5n ever in eaeepl boll and m 1,
which are all that will be NN after call on.
Fdloxing eremahon,Me crematory will bake reasonable efforts to remove all of Me, remains and o1M m Wdal from the uemetbn
Topped.WI some minlmel dug and residue will IIXely be I¢n behloa. The crematory will sepnete unicameral and foreign materiel M1dn
thy remains and Me message and ldell mabNl will ber d'npoaed Of88 repaired by law. The cremated remain will be meG4nictly
.1Wlx mtos Mllpleadandplawd 'mtoadesignedcoMimrorum. CMMMdmmoMsgaoerallyarepulverizedunUino
single fragment is recognizable 86 skalml Ogg"
OPERIBIGOF ECONTAINER
no crematurry may only open the confiner boiling the uoSr¢malea human remains In gmied damffinms,such as to WO mMB
beentdy of the aemased or 0 ensure Met no fraWnal Is enclosed Mich might Injure anpbyres or damage Me cmmMV Fall ft
human royal Me an dWWgsa In a owned Mr which Is net sun le for eMneNon Such a6 caremoma or rent mW.Me
nfirl
consu cr Me longer feet
rr remoxl of remmanMerged
wlii be conducted Werreaalleges eM anti M done inoearay win dre^n and mepecl.
IDEWIFICATION OF DECEASED
a James R. OSNmn All Shcw: Drcorced
Name ar0emae a.
Lag thrown Admeaa. 23 Burning Pines Drive. sal aton Spa. NV 12020
Plain m Death Deceased's Residence, 54 Sodom Cross Road, North Cmek NV 12853
Sep. ®M 13F Aga: 83 DOB' oW13/185] Mee a Deem: Wngn020 Estimated welvM1c 175
Description a vwAwMgmmgdm In Mil remalns will be:delivered.
Florence Casket-Deluxe COMaiMr
INTIRCH,OF DISPOSITION
freraonfs) manmramaPomron, �oNEa Ma rdmwiriy
I all are Me aesgnated Agent OF the Managed deuvem d In a win or wheat InaWmem eaemT Plasmas W Public
Health law sammn 4201.
OR-
rr
✓" AN,have no knoWledger that Me dac¢aam averaged a shown nonevent waWmM public Hamlin LOW Section 4201 ova
till Nursing mremons for the dleposlnon Of his Orbd remains and has min Me ranging)coming frou under Public Neelm Law
Section 4201 and have Me rgmm instance cremation of the remains of aeWasea. My urmWiammpWMa Mceased Nas
an w :
James R. Oshorn
Page 1 a 3
DOS 1891Lf(Rev.M M))
r Authorisation for Cremation and Disposition
nni fium the AS bei
Number. 3 oeacdptioo:Surni Child
1. Aperson desgnated In wrAig rumored he Public Heats Lee$soon 4201(3),
2. The auMW%apcufe'.
]e. Pie survlWnq domea4c paler.
3. AN rorvmnq child anscon years of age Or older,
a Asurvimng mrent:
s. Asun'mna✓brow eghken years 0 age Or older:
S. A lawfully appointed guard Or
r. AN penni mgnoen years M age Or older entitled to share m the estate and who team firmest in relamnshm Wate aeneewdl
s. A duly appointed fiduciary a M ,estate:
a. A clove, mend or restive who has executed a women statement pursuant to Pubic Heath Low Section Qol(a)',
10, Ach'if Mewl officer of a wumy or a public admmistai appointed pursuant to the Suttcgate's Coon Pm®dum Am
1M. MyoNer cersm who is aceng on behalf W Me cowrie]and who not evewbd a woollen statement Wrsual to Puble,Health
Lew Section 4201 tq.
(IMa1 ALL NeREE Of MatAmOot
J0 Me hereby affirm met the body ofthe command does nM contain a MAIN, alfery pack, power wu, mdioecdve andenl.
Or rmdloedwe device and Nat any such matoma were temowas prior Atha ea radon of the Awmwmw cur Farm. Faitun W remove
these Items poor b cremation may mutt In harm A the axntoas and vemstory Manic .
JJO HAS spin NallnaWcrms have bon given to Dari AlAlemnnder
regarding the removal of any personal pApenyotoNer Olnq of value which any peo rn signing below or my sandy memberof the
deceased wishes A preserve. Pine View Crematory
is not responsible for Me removal of personal Items Man the summer
sum e Om Pe remains of the decease terroat lesions left in the
an�ttirr1nser or with the remits will be destmyatl Ly the cM ion pre one Secret be re levee after cremation.
See MheebyaNhariae Pings,VIEW Crematory
xwr to crmmate the mnalns of the decessec.
(lomea; TlONAL1
INn hereby auMorim Mm named funrral cireclor A provide fair delivery to and cremation Me an albmte
reMm q,H deemed necessary in ate opinion 0 Mefuneral director, and to amne this form to provide the correct name and
address of Such stomata cromabry.
FINAL OISMSRION
We-Ni to shadow the ad remains Mike eemas Mom 1M vmblpyis,:
Name:Alexander-Baker Funeral Home, David Alexander
Address: WN Main Street Warrensburg NY 12885 Prone: (518) 628-2055
TM aemeed remains,M N_cased will M ciapm N M es follows:
Rea to family
If for any Mormon ate peon named above does not tale MeaeeYon of and awruMd remairm.
Pings View Crematory Is aumodmd A give possession of
Me remains to Alexander-Baker Funeral Home by Mlmery
in peoon a by higiMrcd mail. mevsx..w James R. Oehom
DOS-tag&f Ukev.01 w�. Ppe21ff3
Authorization for Cremation and Disposition
t�and morel
OJT IMbamemandMelaNammeidaamnamimeawMMlXi�eremmadmmn.
Pine View Crematory may boxes a the affairs 'in
iftrall.,mt
an im ewble manner, Sam as by command.
CREIMTION COMNNEMIIRN
draol ME of the kgment
Alexander-Baker Funeral
_Mum to MuaeO eae concerns krtlm uemabtl remains area been purchased teem w.c.
and is dasuihed as names
Me underWM Mal it INS um is for Small to hdd tlm earned vnnaW r M,an additional road ankMx may be aced ter comedy
-OR
07D M um brit yet purNeeed. Inge,andow"Met if im um 'm puMaeat or Wnrwise proideO
Pine View Crematory yml place the crammed remains in
Irw.acmemi
a rigid temporary container for delivery.
mms Aumontarron Form was provided by David Alexander was executed at
Alexander-Baker Funeral Home
3808 Main Street, Warrensburg. NY 12885
Said is signed by Ma Nnerel madder as shows;W As eawutain
Me have modified e compbted copy of this Authorization Farm.
TM panaMq iderdifi Wow ishares Me immortal in control of estimation,who by signing this AuthotlzaNan Form. eas tis)
to Me accunry and completeness of the iinformation contended in MIS Awhorin(mm Form and authorities)Me bnaoirrg.
Stood MIS 30th dayef July ,, 20 //22/0
Derek J. Osbomy�-
21]] Bannac Avenue, lake Placid, NY 128A8
s David
avitl Alexander J
10039
James R. Oehom
DOS.18W(Rev_04I20) Pie 3 rid