Tubbs, Michael Pine View Cemetery 8. Crematorium
Quaker Road
Queensburyl NV 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME:
-- .. _ . ... RETURN TIME: _
DATE 8 TIME REMAINS ARRIVED AT CREMATORY:
NAME OF FUNERAL DIRECTOR ORRyE�GRISTERED RESIDENT DELIVERING NEMAINS �
NAME: __._.___. 1—
CgSE A _
TYPE OF CONTAINER: __---Ill at"— kilt
PLACE OF DEATH: _ _ QFq
ESTIMATED WEIGHT OF REMAINS S CONTAINER____
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION:
TIME STARTED: _2' E0 nn 9 30AM
TIME COMPLETED: _
PLACED IN RETORT: q,_98 AM MOVED: _ 8: gcgry y,,,
RETORT A IN WHICH REMAINS WERE CREMATED: $ -XutLOKr-
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 43 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SHALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
NO.YIN el
NYORK ° 'u° ° e" T "'EsST l OWcePN mi
Cemeteries A°wa'b„mo,a,aaM
e.P ,e I5tal474422e
Authorization for Cremation and Disposition
This Authorization Form must be complaint and Signed prior to del wry M remains for[remaCon.
Die:B/5/2020 Number gq9
crmmwyN. Pine View Crematory
Duakw,goal OueenMury. W 12801 518 TaS46]r
Addri Pero'
CREBATgN Ia AN IRREVERSIBLE AND FINAL PROCESS.
Crerfulbn is O nied Mt by plating Me remains M Me declared and Me central holding the remeina hW a vamation dunberwr,ue
Meyaresub(cledto In@nwI aMflame Th F and%me hind H Wamaamumes"e irpeawp Wmandm 1,
which are an"twill be IeRawr mmadon.
Fmmvnna rotation the crematory will take reasonable Mork to remrne an of the remalna and other reach)fink the cremation
chamber. but some minimal To and residue will Isom be kfi behind The crematory will separate Marshll and roreign material ham
the remains and the incidental and kreigh materal wn broadcast Ma reaNred bylaw the oemebd rememavnu ba rrMankaYy
pJlven:nl into smell gases and placed into a designated container or um. CMnatad remains geraralh an pulwrimd she m
apple hagment ie recognizable as akelatll Team.
OPENING OF THE CONTAINER
The venally May only open the containerComm the is emceed which
nt msamIimhM circumstances much as inn&m VA
Hanby reMe ns am din iv to ensure Del hoer whit is snot sol which rune injure empbyres or dandy MeoremNas et Me . N
human retains are delivered M ro[ens i e wM[M1 a not Soluble
brcrematlon au[M1 as ins there ai s. malTr chew Me
Mabry will requireMttthe remainsbem ovedInbactedwhma aigreed and it he don Meremains. n despelling red
mnrainer or Me transkrar remowl n remainawill be aatluped texture a wMess and will be done In parvery, vnM tlignty and rrspM.
IDENTIFICATION OF DECEASED
Name of Deaessad: Michael Tubbs maned sbka. Married
Lan renown Address 433 Old Stage Rd., Lake Luzern, NY 12846
Pla o I3emM,. Glens Falls Hospital, Glens Falls, NV 12801
sal Elm [3F Age'. 72 Due 6/1 Dab of Dearth.8/5/2020 EstimaW Wages 220
Desrnpdon of mskeg¢ntairer in which rembM Ngl be dells'ered.
McDonald basic cremation container, no interior
PERSON flyl CONTROL OF DISPOSMON
(Parson(¢) on mnlyd of WsmvYbn, BONE of IN MWairod)
I Met are Medesgnaled agent M Me demasa]demmmakd m a will or widen InaWment executed Noisome to Publk
Hw htaw Section 4201.
-0/Rl
w INJeevesfMnmNdepo that the disposed barmmuneaawrest innmmaepursuant to Public Healthunder Law SaudiHealth
tall ors
way containing directions for Me To weather
Mesmmr remeina and lack are the Por . S having r Anion hip AMeb Heasetaw
Section af01 eM have the ripntro auMava cremedon of the remains of Me leased MylOur relationship 10 Me dewaaed is as
follo n:
Michael Tubbs
303-189Sf(Mark 08115) Page 1 of
Authorization for Cremation and Diapoaftion
t//ff rarowxg)
J i understand that nme rca are m command aMM1m tzoaeySacremellon.
Pine View CmmMsry may dispose Of M rememaW an Mara a manner, wm as W wask kg.
CREMATION CONTAINERNRN
(TONE of the Wooing))
An An W W used as a oMWnV fp the mmtl snore has Caen purchases from
and is dayse das pulses
Lee,understand that if be um ia may"I to hard the more a an remains, an Wdtional red Promise My N used for aouery.
-000R�II
y An um is nW eel WmI'ae MMe undersmM eat ifnoPon is purchased or otheraiw provided
RneY Canadair
Per piano be decoded remains in
a toga Temporary eonmlner he ceovay.
Patricia Miller was seasonal at
This Ambassador Form now provided by ex�uomxenr
Brewer Funeral Home, Inc.
24 Church s.. Lake Luanne. NY 12M n`"'u ema
and is agNdey Ma brands directoras vAi W its exhissupon,,m�®t
owed have removed ammpkted dopy of this AUMW OV= Fmm.
The
i managed takes,isfare they
e In morprol of
g those Aunfrophummon Form,
bYy accuracy and cmnplem nwa of the O bsorpton contained In MIs�AUMorization base a stamps)
and auMorlwte)Ms fine8ol g.
Signed big 5 day of August is 20
Paula Tubbs
4330B Steps Rd., lake Ll2errle, NY 12RdR
VVI
Pence Mllkr cIT)RG_a! d 'L]YOYtJ
*Aivnmx ? M��sr
12445
Michael Tubbs
DOS18W-f(Reu_oflr16) Ramses
Authorization for Cremation and Disposition
n��Ine x»wro
rvunber'. 2 ..Pt,. wife
1. Acerxn Cesgrated In writing purwant ho R.MO Hm May,eetim Asig Oy
2. The summers spouse',
b. The mmving command partner;
J. My euessom child eighteen yeas of age adEeu
C A surviving parent;
S. A surviving tal eighteen years Of no or all
6. Alyou ly assumed mermen.
). Any PTmn(s)elphteen theory of age or older wMW to share In Me estate and whodead,closest In ressionsM1ip he the therms tl;
8. Aduly appare led fidutiary of Me eAate;
8. A days,Mend Or hall wed lie emwlM a wnMn statement pweuard to P U Mls Health Lew Section 4201(7)I
10. Achief model Order of a county or a public adminatualor appointed painful to the Sunoaate s Court Pro Kure Ael;
10a. Any harder summer who is tttinO on Woman Of the demased and who has emwted a written statement puauaM to Public Hei
Lew section 4201M
(4ry(jgI ALL THREE Or me,m agu iy)
IAYe hereby affirm Mat the body Of Me demasM deals nth COnbm a Wa116Yy, battery pack, Power Poll, radteadrve hundred.
or u cioeyve de+ise and Mad any such mOmnab ware,removed pdorlo Me eipakon of this Authorization Form. Fallu e W ramose
Moral IMms prior to Preseason may meurc In harm to lie smnalary and Name"p andmnel.
Or pmµ
1� U IMpnch Pi lM1el humorous lave been pnenb Pedma Miller
appeal Me removal of any cesOnel moment Or When thing of value which any pnaon Wignln0 bete,or any fulyn mbar Of the
Pine V Cremetwy
demesed Maine$to preame.
..mvwa
is nN reaponsibN for the remm'a1 of cersmM Idanshon IM Wnlaineror M1cmiM earmans of Me deceaud. Pomdwl ipma Ie,n in Ny
mndimrorwIMMemmaiMwnlbe Me yedby1Mmemabonprmwaendp nOW s ieveoaftercremation.
I Pine Mew CremeKry
` M's Mreby, moral
loons"+arwel
by inmate the remains or Me dapeaad.
FINAL DISPOSITION
The cemon aulMrized to rdd,l the vemned remains Ofthe dowsed from Me cremak ry Is:
Bream Funeral Hone, Inc.
Name'
24 Church St Lab h¢eme, NY 12M SInsal )M
Addmas: Phone
TWO raemtled rematm Of detvasM sell be diepased of as fall
return W Paula
If her any rm n the wrest named a d ve does net bb masesalon Of Me cremated real
Pine Neer Cmmakry
is aNhanol to Ave powsuon W
Me remains Up Br Fursral He". lnc by delivery
in per or by re ial mad. e�ervwnw
Michael Tubbs
em.wm....a
DOS 180f(Hhe =15) Page 2M5