Murray, Lillian Myra (2) Pine View Cemetery g Crematorium
Quaker Road
Queensbury, NV 12804
(518) 745-4477 or (518) 745.4476
FUNERAL HOME:
-- - RETURN TIME: 40"
DATE & TIME REMAINS ARRIVED AT CREMATORY: _ 7-3/_&go
NAME OF FUNERAL DIRECTOR OR REGRISTEREO RESIDENT DELIVERING REMAINS;
NAME: .__ L���i4n Y✓l/i/a
T
TYPE OF CONTAINER: /�_._ /. ®� _�CASE P
PLACE OF DEATH:
ESTIMATED WEIGHT OF REMAINS E CONTAINER___
PLACED IN HOLD:
PLACED IN REFRIGERATION: __
DATE OF CREMATION: _-L. /_ 70W
TIME STARTED: _ /gpA.n _ TIME COMPLETED:
PLACED IN RETORT: /W `--Y-�
s — _MOVED: /f_—l- f)P
RETORT i IN WHICH REMAINS WERE CREMATED: _ 5�DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MOREA2t 42K _
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SHALL E RETUNED IN THE PERMANENT FILE OF THE cxengiapv.
Authorization for Cremation and Disposition
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Tom Audwrization Form muafbe romplatatlantlafgnatlpfbr to dagvery'ofr ins for cremation.
Data ` 0`3)-aaza Number O SG
Cematory Name: P' U C alory
Adds' Quaker RE Queensbury. NY12804 Phone: (618) 14544TT
CREktATION IS AN IRRENERMBLE AND FINAL PROCESS.
Cremation is wined out by placing the remains of the deceased and the container hOltlNg the remains into a
cremation chamber whore they are subjected to intense heat and flame. The heat and flame will Incinerate and
consurne everything except bone and metal, which are all that will be lea after cremation.
Following cremation, the crematory will take reasonable emons to remove all of Me remains and other materiel from
Me cremation chamber, bid some minimal dust and residua will likely be left behind The Crematory will separate
incidental and foreign material from the remains and the inc:dental and foreign maternal will be disposed Of as
required by law. The cremated remains will he mechanically pulvenzed into small pieces and placed into a
designated container or um. Cremabtl normal generally are pulverized Until no single fragment is
recognizable as skeletal Hestia.
OPENING OF CONTA NER
The crematory may only open the container handing the un-crenated human remains In Ilmia:d circumstances, such
as M confirm this identity of the deceased or to ensure Mat no material is enclosed which might injure employees or
damage crematory property. 1 human remairw are delivered! In a container which b not suitable for cremation
such as a ceremonial or rental casket, the crematory will issues that the remains be moved Into a suitable
container Won it accepts Me remains. The opening of a container or the transfer or removal of remains will be
conducted before a witness and will be done in privacy, with dignity and respect.
IDENTIFICATION OFIO S A D
NameMDeceeaetl'. /L/�� ���� Maritai8tabs.irnmetA
Las[Known Adtlreu' OSJCj ter. ` 1N�((\��\ \N .1iw-,SYirV�_ Ny \1A� y
Plow MDaelh: GIPM �114 Ii0 pt?Y _ J /--, I
Sex: OM IF Age:� �dIIw DOB: �3111� 19U'a. Data of Deets'. O�11C2h ]O EstimeRtl VVNght\?, \
Description of wskeGwntaicer in which remains will has delivered'. T�'�'
CORRUGATED BOX
PERSON IN CONTROL OF DISPOSITION
(Perri 0 wNd Wdlsomsfin. ,hats ME of his hPomhH)
I ant M are Me designated agent of the deceased designated In a will or wafter uretrument executed
p uaM to Public Heats law section 4201.
-OR-
IA4e have no knowledge Mat the deceased executed a written instrument pursuant to Public Health Law
abortion 4201 or a will containing directions forthe dlapcation of his or her remains and (cawnueom.rpepef
1 11
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I aM we are the persons) having priority under Public Health Law section 4201 and have Me right to nominee
cremagonofthe remelnsofthedecessed. MylOurmN nshiptothedec sad asfollows:
(smart hap the list below) ` ` o
Numi Descrpfion:
y A person designated inviting pumuantto Public Hei Law section 4201(3);
2.11flim surming spouse;
U. The surviving domestic partner,
d. Any surviving child eighteen years of age or older:
C A surviving parent
S. A surviving sibling eighteen years of age or older;
6. A lawfully appointed guadlan;
7. Any person(s) eighteen years of age or older enoled to share in the estate and who Were closest in
relationship in Me deceased;
S.A duly appointed fiduciary of the estate;
6.A close heard or relative who has executed a written statement pursuant to Public Heal Law§4201(7);
10. A chief fiscal officer of a county or a public administrator appointed pursuant to the SunogaW's Court
Procedure Act
10a. Any other person who is acting on behalf of Me deceased and who has executed a written statement
pursuant to Public Heal law§4201(7).
h gf0ffi ALL THREE of Hre Mlowiy)
1kMe hereby affirm mat Me hotly of Me deceased does not contain a battery, battery pack, power cell.
ta ve implant, or radioactive device and Mat any such materials were removed prior to Me execution of this
Authorization Form. Failure to remove these Items prior W cremation may resph in harm to Me cremmory and
crematory personnel.
Me hereby affirm that instructions have been given to pummernurnuny Sw Baker LFD#10159
regarding the removal of any personal property or other Ming of value which any person signing below or any family
memberofthedeceesedwishesurpreserve. 2emummnnl P'ne View Crematory not
responsible for removal of personal hems from the container or from the remains of the deceased Personal hems
IeN in the container or with Me remains will be destroyed by the cremation process and cannot be retrieved
after cremation.
Me hereby authorize (wir,mvmel Pine View Crematory tocrematethe
ofthe deceased.
FINAL O SFOS T ON
The parson authorized W receive Me cremated remains of Me deceased from the crematory is.
Name: Baker Funerel Home
Address'. 11 Lafayette Strict Oueensbury, NY 12804 Phone: (518) 781-9303
The cremated remains of deceased will be disposed of as hillovs:
RETURN TO FAMILY
If for any reason tree person named above does not take possession of the wematd remains.
yewxxa ,�) Pine Vlew Crematory is auMOr¢ad W give possession of Me remains W
neawth.i iimwl Baker Funeral Home by delivery in person or by regisWred mail.
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I VVe understand Mat if the remains are not chimed within 120 days of cremation,
Ivemm,y,r,q Pine View Crematory may depose of Me remains in an Irretrievable manner,
such as by screening.
CNEMATON CONTAINERIORN
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An urn to be used as a container far the cremated remains has been purchased from
Baker Funeral Home antl 'a described as follows:
WJe understand that if the um is too smag to bald the entire cremated remains, an additional rigid container may be
usetl for delivery.
-OR-
An um has not yet been purchased. Wye understand that If no um a purchased or otherwise provided
r ) Pine Yew Crematory will place the cremated remains In a rigid temporary
container for delivery.
This Authorization Form was provided by rrvYw.leu.aw,wro) &art Baker LFO#10159
execNed at�nw.wwx,Mw Baker Funeral Home
m.re,.lmm.amress) 11 Lsheyetle Street, Oueensbury NY 128oa and is signed by the funeral director
as witness to he execution.
IANe have received a completed copy of this Authorization Form.
The parsons) identified below Were the pedicurist In control of disposition, who by signing this
Authorization Form, attedus) to the accuracy and completeness of the inform"on combined In this
Authorization Form and aufincr s)the foregoing.
Signed this day of W
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Burt Baker LFO#10159
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Funeral Home Reg. 01130
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