Dobert Sr., Marvin S. Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745.4477 or (51 a) 745.4476
FUNERAL HOME: —_g ES. -
-.._____,_ RETURN TIME: _
DATE B TIME REMAINS ARRIVED AT CREMATORY: _
NAME OF FUNERAL DIRECTOR OR REGRISTEREO pES1OENT DELIVERING REMAINS:
NAME: (y�ipf
TYPE OF CONTAINER;
11-tg91L
PLACE OF DEATH:
ESTIMATED WEIGHT OF REMAINS B CONTAINER____"__ 1�
PLACED IN MOLD:
PLACED IN REFRIGERATION: 'jro Ah
DATE OF CREMATION: —
_ 4)L ( A
TIME STARTED! ___ Q20111'(1 TIME COMPLETED:
PLACED IN RETORT; g b p u
RETORT p IN WHICH REMAINS WERE CREMATED:
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 45 RS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SHALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATURY.
o-t Stitt
OF CEM W 5We
TETE j Division of °"°'°"D,°�°m"T'`�';:
°°PORT°"'^ Cemeteries seem, ir
wdmorA�
ekp era.NIOLM i
Authorization for Cremation and Disposition
The AuamfizU FOIT Must W completed and signed prior W dalMryal meeting for oriental
aW. 0810413030 Number ti9j,
Cmm Name;Pina View CremBbllum
rdemas:51 Quaker Road Queensburv. NY 12804 Pane; (518) ]45441]
CREMATION IS AN IRREVERSIBLE AND FINAL PROCEU.
CRMa40n is canted me by plating lye remains of lye deroaxd and the container hoping Me remains auto a cremation calendar Wt9e
they are subjected W intense heal and flame. Theo and time will Inclnamb also museum@ everything except borm and inY1.
whim am an 1 W l sell be bin~examined.
Foliawl orientation.Me uemabry will take reasonable eflMa W remove all W Uw romans ant other maternal from the Uncurl
chamber but some minimal dust and Men ue wiii likely ce left bermil The crema"ry will sepame Woldenla and foreign sealant from
W remainsand MainadaWlant nmannawnlibe UiepowdWamTuired Bylaw. Thecrematedremainewiiibe n
portal into small piemsaM placed i a desenN cWnemum. cm nmlm pnemlNen ulwaa undi erO
sing hymaM b m[ugnyble As skelWI UMW.
OPENING OF THE COWANER
The GametOry may Only open the container holding Me urvcremaW human remains In limbed circumstances, sum a$W comrm Me
wentry of Me deceased or W ensure thin no mal is endows when might insure employees or damage Me ulmon ry propeM- N
human remains are dallvemd Ina conulnerwhich b musufable Wr cnmMon such as ceremonial or earned seems.New
metal will mauls that m he retim be served into a subsidy scandal bN cce om it ms W the ra . The ope firs Wa
ummer or We transfer or removal of remeiM will be conducted Wlore a names ant will be done in phvxy, wM diilmly and mpM.
IDENT F CATION OF DECEASED
Name of Dessmaed-. Mervin S. Dobart, Sr. W WI SleWe Married
Lest Nroa Addreee:l3 Lakeview Drive, Queensbury, NY 1280 t
Place of°nth:Glans Falls Hospital, 100 Park Street Glans Fells, NY 12801
Se.: 19As OF Age: 83 DDa: 1110yigm [additional 08I04/2020 FeMnam Vg@IgM: I'JU 1b,
Rscnption of uskeumntaimm in when re ens will W"I"W.
Bul Casket Company—Alt container
PERM°" M CON11ROL OF DIMPOSTON
(Person(elln wnrM o/Oisas§im, mill CNE of Ure MYoxnp)
e 4ere Me desipryW@gem MMe dares@tdeagruleE in aunit orwMlm InsirvmmlerecuRd pumueMW Public
H.aM t.w semm4zD1.
oDN
'Me have no knowledge that the warned annual a wrWn inawmanl pursuant W Public health Law eedlon 4201 ore
X M thing01direcons for Maportipn a his or her farmers and Use am ma foraanl tuning pnonN under Foam NnlM Law
4201 arm have Me ngm to auModtt uenation 0Ma immune MMe meadows, Myi relationship to Sam deeueM b we
M con:
Marvin S. Dol ert Sr.
testaments
006-189&f(Rw. 0120) Prese1 of
Authorization for Cremation and Disposition
(Im�fmmfMwM )
ounces- 2 Desoipeon:$
1. A Wmn tleaignaktl in writing punuanlm Pubic HeeM tax Sxtion 421,
2. TM suMNng Wool
L. lie Surviving domestic tanner;
e. Any survving this egmeen years of age orfser.
4. A surviving perem,
a. A surviving sibling eighteen years of age orakm.
G. A hoddly appanLLN guarder;
2. Any mreonlq eighteen years of age or older entitled to Sham In me estate and who Saudis added In rNetlonsbip to the demeeed:
8. A duly appointed fiduuaryof the estate:
g. A Clwe bided or reel who has eveeutM a ended statement pursuant to Public HeeM Lew aMtian 4201Q1;
10. Achief fecal olfirer of a county or a public administrant epfeirNd Willi to the Surrgate a Court Procedure Ant.
10s. My other armed whois adding on beloX M the decreased and who W executed a wMkn $Miemenl Pursuant to PW4c HeeM
tax Section 4201l7l.
(goal TyREE of the Washing)
� —I Intl Mrehy affirm that the body of the eeme does cal WMein a Want, hadery pack, Mrrer Will radiwv9ve i hil
or annual deNm and that any Such Warmhearted removed"W fteveukm ofthu AaM "M Farm, miUnmminors
sum. ynrmamm.eMmar man In MrmmlM cmnrmwy me ammamylemonml.
XInVe efirmnut inwucaMS Nve been glvenro Ma�J. NS�imone
eming the rdnmed of any Mwnel Ixcperly or other bill of rfor which any Mrson signing below or any Wm menWrofMe
ea-emee a tones to premr Pine View Crematorium
rc nN reaPonYbk bflM rertuu9lMpenanelikmS lmm MemmeinerarhOm th remeira of Ce demand. Personal lmmslM In iha
TM iMc wed and maim will be Guards by Me cmmanon poCYa and cannot bat derived after cremation.
yvy hrraby cMcdW Pine View Crematorium
m uemMs 1M nmalna of the decades.
(mfarO TACAAQ
Ihn hereby trade ze the named funeral t hea:lorne providi dagram Wand cnmabm bran alMru4
Oramemry, Ifd"e necessary InI opinionattMNmraldimWr. Mdmamend1M1 foremIxorldrtmca mct MMeM
dM M Such alternate cmmemrv.
MML oismwioN
ism WI adomae to deulwdm aemetM remaim IXtle M 8WM1 led uematory is:
Name:Joan M Dobe t
AddmW 13 Lakeview Drive, Oueansbuty, NY 1281W FMm: (518) 222-0i384
me arm mmeia M MmaW we W dYOaaed a as Mil :
Bunal at f asetoga National
n M any chasm and pmeon MIMJ above does not have ponMebn U the model remade,
Pine View Crematorium reauth mgive pm or
caravanserai
d mm inem Regan Denny $taffor0 Funerel Home by desvery
in pemon or by mgistered mall Macon S. Dobert, Sr.
Dos-18N4 aer.04,20) Page 2of3
Authorization for Cranial and Disposition
r
C/ Inw Waem Ad time
if the ramaam not chimed within caromIAcaromIS mn.
/� Pine View Cremaorum may mapaee Nma remaim;n
awn
.n IrreMewNe manre..anon AS byacenedr,y.
CREMATION OONTAINERRIRN
(Ippgt ONE of the ralbxmg)
Regan Denny SMfbN Funeral
An um to Mu6etl AS Pontaimr for the aMnabtl nmaine M1ae been Wrdmmtl bom .....e
and a desanand as haloes:
INS unaaa MMm OMe ran is too small M nad Me¢mire mamma ousel an.mgmnd rod cemmimr my an u.ed nr dMverY.
/ oR�
�.nmMwamaaed. lrweuMomMMt ynourniscumnasedormhemwpmwdW
Pine View Crematorium will place the cmmamd motion,;n
a Nid bmWrery,cmrelner Mr daYwry. rvem✓gym
mu AUMwli.tlen Form was scandal W Mark J. DeSimone was Savoyard at
Regan Demry StaRad Funerel Home
F,..waw.w.w
03 Quaker Road. Queensbury, NY 1211M
�
and a Syrian ins,the Nreel Sharon as vMreas to its execution
IRYe have removal a completed copy dIris AUMw ae Form.
Me person(s) IdemMed bNox Ialamtlm penont In conval or aspwHlon,"a by lapin MIS;Aug "N Form,aX 4s)
An Me Idea y ntl compal.neu or too lMo on conYlmd in MIS Aupwdaaeon Farm and autharil lMe LmpWq.
Signed MN 4th day of August r20 20
/1. "
Joan M Dobert
13 Lakeview Drive QuaeneWry NY 1200
nn.aamw. ace•
aR1NE08:
Mark J. DaSlmone
R,.ewoi.mra.esm.aw.n �+-
19919
Mervin S. [)aIMl Sr.
mwwovw
W 10a0J(Rev. M2p) PeyeJd]