St. Louis, Micheal Pine View Cemetery g Crematorium
Quaker Road
Queensbury, NY 12804
(518) 7454477 or (SIB) 745-4476
FUNERAL HOME:
—'-ft yy
- Y3bE{Q� -____ ___. RETURN TIME.
DATE a TIME REMAINS ARRIVED AT CREMATONY:NAME OF FUNERAL DIRECTOR OR REGRISTEREO REAL
IpENT DELIVERING ftlMglN$;
NAME: ...__
TYPE OF CONTAINER:
PLACE OF DEATH; �Z i�Lln
ESTIMATED WEIGHT OF REMAINS & CONTAINER___ j4p i1
PLACED IN HOLD:
PLACED IN REFRIGERATION! )D_ir 4.F�
DATE OF CREMATION a _ -- f(6(TO jI
TIME STARTEO: _—_— R.EO yn TIME COMPLETED: z.36Qr1
PLACED IN RETORT: _ �,IO P4---MOVED:
RETORT p IN 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 SHAD BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
rwr oaic cDivision of MMSpCRME;HIIg
O
WRNNI
Cemeteries ewer„sn "",„mcl
Tem "";(5Iw,eAa.2a
Authorization for Cremation and Disposition
this Au aaon Form mull they complaint And signed prom ddMm or remains Wrrm=Mn.
Date'.Aeual!'ZiO Nu . D51
Psmkry,Name.Mm Naw Ge q
Andress,. Oulwr R60uem q,W highs � : 51&7a "
CREMATION IS AN IRR ERBIBI AND FINAL PROCESS.
by 0arms Am rumors urine drummed am me wntainu rholding the remains Into acm.Enn imi wme
they ante subiercted to Out
neat and name. me Mat and name will mcimah and mansume f'nryMlne esoepl Gone and mMl,
which are all Nat will bar Mn after ae bm,
o'ruccrmmation, theaalnatwyvnll bka rmmnable worry to remi all dtM remains and other m0elal darn Me chamber
chamber, GW sorte mlmmd dustand small yell Ill the An behind. The Oem me MII sigma madental and Oman imumal Dom
and m Inoderse am fe lhn msmnd ea Its,dlspdaM OI Aa earyl2d by law. TM aemalad remain.w1l de m mmiscrlW
pull into smell gems and plattd and a desgnN cnMlmw um. CmnAMd r ins gmmlly are wN red untll rw
s Ing Is Rag men Is mWninW as sN l Small
.
OPEN NO OF THE CONTAINER
This y may only open Me ci ri Mkinp Ne mated hum In limited d aucAa mnfitm the
Allreymaw of mr,deessi or M ensure that no mated enchsed Mldl might injure employees w aamyahe the we td prop" 0
human remains arc delivered In a comamer which Is net suitable for crtma don such as ceremonial or rental All the
crennarthary will require Ma Me real M nosed Into a sullaele number turn It accepts the revs ms. TM toms us
container or Me"met or removal of remains vnll be Numbered bi A Wtnwss and All be down phvacs earn dynny and reapem.
IDENTIFICATION OF DECEASED
Nmrerf h¢al Midwel9L Lwi Manual Sams; Merced ud Moan Mdrew: NQ Main St. Humon Falle, NY 12339
K aC m, M Main S.Hudson Fells, NY 128M
sre'. ®M OF Ani WB; 101 1953 Data of lg h.0� Eadtmted weight. 200
Deml M®aXNlmiWtw as all Is mAM they chefwM.
Corrugated cremation Container pine and cardboard
PERSON IN CONTROL OF OMMO 0M
(Foam!(.)in aw't1w w60gas".a"o mMe MNAwN)
I amAe are Me deli mW all a m de Wspt in a ANN or am,immsrcnt ea Wmember M Pudlc
Health (.,romm,4201.
on
lMe M"noknrWedge Net MeamazedeXmt armlPon'msbumentptuwantMPubl'c HeaIMLaw SM'IW4Mlora
all crantaning direchmabr Me diarmitan Of his an her mmaitm and YAS ere the pelawi(y)hw,nq pnmN under PuNic HmM Lax
Section 4201 am were the night to want cmimmon more remans of Medeame W10urmlaonshipMMedew ISM
fall
Michael St. Louis
Ws-189&f(Rev 0420) Page t ol3
Authorization for CrameHon and Diapoehion
fbwNlmm mer¢twawi
Nun 2 Desmipdm: This wmmnp e{w¢e
1, neersm speletl In Mory ryrsuanlm PltlkFkvM 1pn'9egm/]01(!j;
2 Torsurviving hw ¢oc t
Y MYTher wrvrvinp<ong egh e H
5.A. A o,n vinarent,egllhen yeen olepeoubs;
A awvirnpp WIN
5. maghtern dace women
6. AIawlWlV (s) inlnd hte,many
My only
appo)egM1leen yeart or ape ae rider enfiWtl mMare m tlreeabbaM and i4art cbse¢11n reladori¢Np to the Oeuu¢eE;
8. Atlo¢e�E obi reth v In ph e fiductary,of has xecuted av fifth statement Wrsunl to Puble Health law Section d 001(]1;
10, Achoel fiscal Won,or a munlym a public adMAllamm,HdW ¢ua^Ho for Sunogain s Court Procedure Actl
10a. My Omer person wlw is ac9ng On penatl Ol Me deeased and wblua mewled a vditlan sbbmer pur¢uanl to Public Heald
Law SaNan em1lT1
lMNaI ALL THREE of OR,knowing)
l� me alRlm Ned this body oldie mammal does rel vnlain a all Imh pack,pwrer WI, radpawveioa 1,
orrMuecdre davlw xnd NadanV suGi maledels were remaved pprlome mewKn 011MS ANMruaOm Form. Fadummnemove
pNess he=pmr m Mmetlon MAY mum In Mann m they Melalary and vemalwy personnel.
Meal NadlMm shave Wwplwnm NNe101hi 0.m
mMdMip Me remodd deny FuglNpopsl wa Nyig civilian v.NN any p¢rwn signing ml wanylmlly memEmd Ne
dewaud vn¢hesm pretene. Rro Yw(tranLry
I¢m1re¢pm¢Ielemr lne removal O(Iersunel ilem.M1mm nce mMarera nom lM;amaina of Ne dacea¢ed. PoR nallmmslMmNe
yCa iW*r*th Me ramalna will lie mstrayed by Me cx w graces¢and canmlEe rttmaed aRr a ae on.
awe narebly anhon>< nine Vi "cremmory
iasrvrv+l mdMlab lM rwi im a the ft e .
1nA4 OPTIONAL)
Hie herebly,auMmlae Me named Nnenl Monarch to pm for dNNery to and crematlan Ey an aRmale
confinement i1 deemw maw In the opinion at Me Nnmi director, and to amend this corm to prow ode M eomtl name um
address If such aMmale cmmalary
FItIRL DISPIMTKIN
Th,lcmm auffiir m rewlwtlw aennW remain¢U tle chum 6ormthe lYlpy M'.
Name: M.B. Mil Funeral mares
Address: 82 Bmahyl Fart EMNN1 NY 11825 518-7479X5
l upreredramem Cta ¢ed WIMdY{s�itl N an Mbas'.
�un(a/ a ! S� l�nair (emr<rPf.
how a"moon the namMaWve rims An AM Waaaaaun ortlM WruW raniayia.
Rrevav cremsNrY reaWYhM NdwP Or
Me remade to M B. Minor Fuwrtl Xome � MyMgyy
on pm¢m Or by Wp¢ min Tr.wa+ �M.Lati¢
0OTlawbf New whil M1wd Peal
Authorization for Cremation and Disposition
f�l¢'�1'n(e nwb„inpl
�C11�MAhe Mdert na MM K he wYuine are nN CeomE J lmmnNam9m,
Poe Upx Creel
nt�a�N nMY NOWeem M.rarnM.s In
an in,YMvade Metal each as EY glbenp.
CRNMA WN CON]YNER ARN
(Mill ONE at me ambi
M um w be used ee a wnhlmc M tlN vaned mmNm hp Netn peplq t Seem
aM a deemLed as nal
man uMenlald Tat If ma um as are smell b most mr andeas NW misle,an ed9tlggl aged anMewrrlmyeeuW bMhwy.
Ofl-
V- �'-`-.7.-,x.mwm»tweel..ee. Im�.um.I.w TetxnonmNwlw.ee dddr,w,e.wn�e.a
Rm Vvx Genlaluy
Paaervvn will glen tlu aemsW mpwM
e tlpW tempaeryanMTeekrdafvery.
ills Autl zal n Farm was prorated McK�Kgnv
M B. Kilmer Fura li nuwwrM4
V Bmnhii Fat Eduard W13 F�as�ru
And ua by Te Sma l dlretar as rripem m Ia Centralxr.^vmrr0
lNb Mae arbaned a ampletM mpY of Tie AUMMIZatlan Farm.
The[aMan(s)tdenBltM)below lsrams Me petards)In small OdMpm .Wm W signing MIS A�Fam,atlesys)
m the Metal and mnlplelenNss m Me Inbmmtlon tanyMp M MIS prMarbetlan Feeds and MMnphtda)Me iMp W n0.
Slgnad MMish MIS ae Auent ,mm
Lads Bt larN `ia ��..... • � �
AI KYMSI XWVIFaW.NT 13N0 �v 1`il l`
seal
deal
sari
reveal
1g1]tHY:
KHe KMv
W] w
MNluMbl. lph
W Ilaailites,01F111) PpeStl]