Smith, Clifford Pine View Cemetery g Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (510) 745.4476
FUNERgL HOME: _ y
-��'_ _ ____ . RETU0.N TIME;
DATE & TIME REMgINS ARRIVED AT CREMATORY:
NAME OF FUNERAL DIRECTOR OR REGRISTERED RE
SIOINT DELIVERING REMAINS:
NAME: _,_______ LII r _(S�M'",±h
TYPE OF CONTAINER: Fgr10 CgSEpZ
/'� I - Imo,_
PLACE OF DEATH:
ESTIMATED WEIGHT OF REMAINS & CONTAINER_ . Zf0 —
PLACEDIN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION: —�—'
alvlm
TIME STARTED: ___ Ml IZAOpn TIME COMPLETED: Z/OVKPn
PLACED IN RETORT: mnf -MOVED:_ _ �•Y+ tT
RETORT p IN WHICH REMAINS WERE CR-EMATED: _ )
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 40 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SHALL HE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
NEWYORK Division of uwsmrwntorsum
SIATEOF ON OFEnE1FA1E3
° Cemeteries mmm .w
T.I1Albert' dm4M4i
e
Authonuhon for Cremation and Disposition
TIIIFAUIMMBtlon Fonn muetW completed and marled priors aellwry Wremain.MCr "on.
Di:Audi 3,3020 Number: 119Z
Cr a" Name Pine cmmelcry
MM,eM:21 Wakx ROW.O "MWq NY lR PWw: 518-7454,17I
CREMATION IS AN IRREVERMBLE AND FINAL PROCESS.
Cmma is pmM Out 4 platlng has remains On the d9ea end they mn holding✓9 memorm Imo a common Cumber wnew
YmyanmLj to inknsebeataMfi a The het add flame Felt lncimn Lad consume ewraching nwpt Wine and mean
Which am all that will be as chair cm eon.
Following mmelicn, the cremm ry will coke reasonable efforts to remove ell of the remains add other Idebal from the Vemabcn
Member, Wl acme minimal dual and reldco will be kR behind. The cre Ma will epamMmodental and Merger mWnal hmm
00 remains and 00 inddental and Aregn matedal MII Wdlapoey of me neculred by I" The uemmW remains will W Me aniWlly
p hysia imc small puree and da[eb IIWa dankgnaad mMameror um. Cme mmams"mmiyampulwr uMlino
emgls fragment Is MCOgnimbM w Minimum focus.
OPENING OF THE CONTAINER
The uemaWry may only Organ Me container holding 1M umpem and human rwnalnn in IlmiW arcunstanes, such as to Wrnsm the
ident The MmazW onto ensure that no mffinal is encbsW which mphl Injure empbyees ordamaaefM uematayp"p It
human remains an dallwred Ina conMimr which Is not aultuc a for cm "on such as caemWflI or rental call am
re
Wnianer oMbb berful or denverval of mmNna will be cll reeptima Mature mmins Me moved onducted befrra wthen MW All be dorm iinn Wall ww�ih many The eM omslpq,
IDENn
Name of Drummer CIiRoN(s]m� iM slartal status Married
Last Nnnm Address. 'vl V"OPC�1 {7x17i is w y�] a
Pie of OaN.. Cke Falls tkapital.°Mna fused. NY liftl
Ee. ON OF AW:-:WDOB, Gm M NM: Fugma gAdm, 250
DesugaonMgekevamtemer in MiM remains will W dells.
Minimum Cremation Casket, Florence Casket Co. CardboardlPine
!F§mm(al in WnOa'aldbpmFWn, tnRlal avEdme kpmsinpl
YM1Mb are be designated of M 09 dames 1deegnMB] In a All or wniMn Meumerd. d punauet W Public
Health Law Secficn again.
OR
IMy ham no WO'dause Natme des executed a wrM1te iMWmeno pursuaMto Pi HNM law Secllcn<Rat ore
Fall¢shining direCons for the d'eummon of his or Mr remaie and IMV are tM FMw:ms)hmng prlMry under Public Healih Law
SBMan Qat and ham to nphtin euumme=mabon Of Me remains metatarsal MyMurmlaUonsho Wmedesavedias
rolrow.:
Clifford Smith
o0 IM-f(Rev.Mrzo) Page 1 Of
Authorintfon for Cremation and Dispord ion
(Mad maunbww)
N r.2 oesaotlen: 3ro surviving spouse
1. A gmn normal In wriWlp du uMt m hack Health LW SR 4201
survivingL no spouse
L. MY morning domestic paMBr
> Any surnwin9 Htiltl@Qhcn yeas of Sae or clear
A Awe lnp parent',
S. A aunivmg sblln9 vginal years of 9]e as d0er',
S. A 4wNlly apponi 9uarMM
1. nny Isronlsl eiahman years M as or older embed to share in tlro estate and wTo were detest In rela4anehW to lee
e. Aduty appdnt Wooary of me atete:
0. Atlady armed or relative Win has eacCubtl a wnlbn statement pull to unable Heats Law Smlion 4201 p);
10. A Or NGl ofisr of a county or a pilC atlminSol appeametl Wsua no b the S u hopes a Court Praadum Pr,',
104 Nry peer Psm wlw la eating on behalf of to tleweed and who hem executed a Olden statement pummM he m ed HqM
Law Sx 4W1R)
n ALL MREE Mete Idlvavnp)
�L lMb hemaya ffy that the body of the dews d does net Wntam a batten factory mucr, power call.mdleecver ltheme
«radlwmvedevicuantlthmanysuMmateriaW"remmwetlpriormtraere onMMis Aolh "MFwm. F.IWMmremove
Maine Nerve pdmm Cmm mn Wry nsun in hams came crone and cmmatwy conventional.
/Y J 1 am" man losW om have any,Oiven to lead O. Kerner
re9ntlirq 1M mmoval of any wMOMl propnN or other tnlrq Mother which any human WgHnO bnoc or any campy memoriam Mme
aereamd wahas or remove . Pare Vitro Crematory
is not removal far ft emovm of pMMnSI Items from the conyiMr or from ther eiemama of May annual Ferwnal Items tall In me
conmfnsrcrMm me rommus well OaG "ed by"cmmanon pmau and cannot be rNMved afar mmalm.
ni s Aft hmebyemhoda other Van Cremation`
to cmmate me nmafa of care deaesed.
InmW OPTIONAL)
has hemby mumorlra me mum"mnml mmcmr to provide for delivery to and mmatlon by an aMmm
msmry. Ndammed necessary In me opinion of yen Wrists$mmcmr,and m emend this form to provide the camel none awe
adds M Such tlmmam c n mamry.
FlNAL MS ITION
The pwwn authohatl to tamale me mmalmd remnne cfcare named hmn me C atory es'.
Name: M B. Kllmor Fulled Hang
AMress: U Bryyd'em, Fort Edward ley 1=8 P1lema 516141.5255
no psmated remains of beceassd art he dsp da$pall:
Released to Mrs. Smor
It far any mason 1M Masson named even d rid been pnaeWm Mtlec WRemain,
Pine View Crematory lMantto 9nea on of
(Counsel Ie a
Me remaiM b AI.B. K1mer Furrerm Home by dNlwy
pew
In arson or by spinere]met. CliNom Smith
O0$ 189"(Rev AbR0) wnW Pape 2 of
Authorization for Cremation antl Disposition
M/alma womlfew
WJe uMarsleM and it tlp orders are naammed wilM1m 130Eys MgemeEon,
Rrw Vyw Cremarory
m.y a'epaw nthe mmemem
enimpieraNe manner,wM as Gyscaueriry, rm cnmuex
ll�l grorvE come meadmi
_Mum W I ream]as a container forme Ferri remains has been rumama M1cm
and a,asserted as ro lower
Imp Wgyr w Mat ff he um Is me small m hold My mere Cremaka remains an addi4T¢I l consul easy has used W asymeIY
of
An um is not may puMaee]. YM methanol May Jrm um re puMawd IXdMrWse pm+Idea
I sell Cmmebry
mereuaa� wall piaw tM Coal rynal in
a NO lemons candhM for ddrvery.
thISAUNor/tetlan Farm"a prowled by Todd G.Kmer wa¢execuied at
M.B. Kamer Funeral Home eras-uvn
82 BroMwey, FM ECMN, NY 128M rraAWrw.wr
and Is sigrred by Me ful ereclm as Wail torts maximum.
li hey rumored a mmplsha may of M'q Authorization Form.
TM mall lal ldenNW Lslow Isla he the pars lsl In tonal of dispeltloq who by aided ng NM AUMONatlM Form,wri l
bee smu Ml and wmplebNw of Me Inbmlal contalnad In I AUBrMbral Fords and auNmlmisl ma fom8oing.
d blue are d oI Mg= _8iI{pN W .ID p
Ya,wM 1 l
S WC f74 3
y E88:
ToY G. Kamer
wmMuemmrr.w cox w.v
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CM"Man
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