Rock, Stanley Pine View Cemetery & Crematorium
Quaker Road
Queensburyl NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: c/f
—rueiitz— _ ___._.. RETURN
DATE S TIME REMAINS ARRIVED AT CREMATORY:
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
NAME: ._. . _._.
_�---
TYPE OF CONTAINER:
PLACE OF DEATH:
ESTIMATED WEIGHT OF REMAINS S CONTAINER
PLACED IN HOLD:
PLACED IN REFRIGERATION: — (Q.
DATE OF CREMATION:
TIME STARTED: ��2-7A�—TIME COMPLETED: �O-m ,Qr1
PLACED IN RETORT: _ j.V Arl _MOVED:
RETORT At IN WHICH REMAINS WERE CREMATED: _ �:.I
'
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN lop
VE HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SHALL BE RETMNE. :N THE FERmnxevi FlL[ of THE [xEmgioxv.
oN OF Inmsan
onDWmtYOmK �ivision of DIVISION OFrnURRIES
STAiEOF On C mmxn Pees
Cemeteries
story NP1223WOM
Authorization for Cremation and Disposition
The Aumorlaatlm Form must the completed and Signed Floor W delivery of remai//mmr cremation.
raw August T 2020 Number'. %
Cmna" Name'. Piney CmM"
210uaker Ford,Caddell NY 128M Phone 518-745 T7
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Characters erred mR by placing the remaim of the recessed add Me container hol the remains Into a aenxflon G4mher where
WayeresubleMdWirM hedand Mme. The Ml and flame will InclmrateeM consume everything except Wine end mal
which an all rut W it Me leftense sensors.
feema ng aema4on, the crematorywill Oka reasonable¢Bons to Par all of Me remains and other mabNl M1rm Now Common
do mwe5 Wlwme,minimal dust also residue will likely as left behind. The crematory will separab inCYbnral Bob Wrtlgnerall fore
the remains and Ne Incidental and Ideas mamnel wll we riaposer Nas repaired bylaw The cremated remains Mlle meCw]r1011y
invented Imo small pis and plead Into a realical container or um. CmaWremainsgammil arepul"d undlno
amglemgnxme recognlaabla u$Mlelal flasue.
OPENING OF THE CONTAINER
The aemol may on"oPo^the conUil holding the umcremated human remaim In Iimi ed circumstances such As M confirm the
NenchrofMedeceased orto arsurs that no maenalk antiwar Which might injure emmoyees orramagetr9 crmekryprorerly. H
human remains are delivered In a corNlner which Is not suitable forcnmallon such as wnmonlal or ended cal Me
wnMory will rryulre NMtM remains be moved Ii a suiebecontainer WHOM It accepts the remains. TM gemry Me
Mamerathe banner or removal mremmre will we conducted before a wares and will be done In covers,wmi rynily man meta.
IDENTIFICATION OF DECEASED
Name of Ceceaed, Stanley Face Martel Smha: Wtivwed
Last Mnwm Address 659 HMIs POW Rd.Gmm .NY 12M
Place of Oem, Glee Falls HMOI
Sam, Met DF Ags.73 of 04/11/1947 oeN M own 0810642020 FSdmatod Might 175
CnMptlom of eaM Wier in which rerWit W delivered
Minimum Cremation Casket, Florence Casket Co. Cardboard/Pine
PERSON IN CONTROL OF DISPOSITION
(Pams S)inc ofdieos¢vm, wd;4ONEMMerIXbMrp)
I amAYe are Me daprated sped of Has dagger deipnlhed in a will or wnhen instrument eseued pursuant to Public
Health Laws ion 4201
OR
��L.
gQI WYe have no khMMdge Mat the do SM exeaed a written l returned famous of to Public Heady Law Sedicn 4201 or
will formal dual far Me Salami o his«hm remains and If am the persoMS)haNrp ptviry,under Pubkc Health Law
Section 42m and have Me named RUMORS commeal OfMe remans came oeaesM. el'rourrelmonshipWNadeceased Isms
Wn
Stanley Rack
Do&lewf(Rev. 0020) Ppa 1 of S
Authorization for Cremal and Disposition
(NN:m- 3 me weebwl
NNnRer9 0msWod, My wMVlnp Mip additional wean INapasNear
1. A pexn declpnakd N wr2n9 purauam to Pudic Health live Srt 4201
x me surviving mail
L. led aurrvlm domestic partner
S. Any Surveyed child eight nyears M aide or older
0. A wrvlvin9 parent,
S. A mul siloling elgnrean will Of of or real
fi. AIawfullweppolned guardan.
T. My person(s)eighteen years of age or doer entitled M share in Me eabtt aM who iyan doomed in nMdGmhip W he d asW
a. A duty appointee fidudary of they mf ,
S. A MSG lriand or relative he t weculed a written mWmem pursuant ram PumM Health Law SMgn 42otpl'.
10. ANlel noel officar of a Wumy or a public admmlvo-afs appointed µr9mm to he Sumodsm,8 Conn Tam um And
red. Any GMS Person whom eding on edhadcf Me demaeed and who by azeaM a written mail pursuant m Public Health
Law SSCWn 4201(2)
finta ALL THREE WIne
ydlovnrg)
.ffi IMb nertOv afnrm Halted War olMe dammed aoa ml wnbm a nallen.lteXerypeW, poxercelf mdloacMue Mplam,
ormhadmvs devka and Mal any ouch materials went mmouad peter to Me exeation of this Auh z"on Form Failure to mmove
then Items War to cmmaYon may meutt In Meme try ihe cmmebry,and cmmabry pamonnal.
J INJt A"Mal lmoucLNe have Caen givan W Shodahanda A.(Al reewuv
regarding he removal of any Personal proG<nY or moves Mine of value which any gamed agree Grow or am family mm rMthe
decrease wlaMe m preserve. Pine view Manuel
Is not responsible for Me removal of wmow items from Me wnWiw w Me tN 9mdm Of thy,d SSM. Pamanal Ibme Nn In the
coned nor or when Me remNM will Me des y"4ue cmmation pr%ass and canna W raVNvee after cmmW"
yW9alremmiuMarGu Pine vmw cmmmory
to c x Iue mnalw or Me deemed.
(e(yjef OPiIONAQ
Nn hemI auihodza he named adnamed dleecbr to provite for del harry W and cmmaYon I an RWMaW
.damrory. K deemed neciper In Me opinion of lye Ica noel oi Wq Wm l rec and aend idea form to govl Me comet name and
amn of such attemate emmaWq
FINALeISPOSITION
Me mean auhorlaor W r0 W a angfnd remmens of the d6eaaM 1 Me mmemrr I9:
Name: M S. Kilmer Funeral Hahe
Mdm 02 BrmewGm. FM EdeeN. NY 12820 Pgyy. 516707-9M
The museum amended a item W will he diepaed W as Wuoea'
BuI at Marnalmsd CenMry
If far my moon Me n nmW aWva does M ob powddon of Me mmaW r Mm,
Plm vimcmmntcry g ahrVn®d W giS9 Naosaebh of
motor,men
Me remains W M 0. WMer Punched Nome pydNivery
an perm or try miete mail. w Stanley Rock
005-1fkdR-f(Nw.(Sell payal S
Authorization for Cremation and Disposition
Ii Me laluwing)
._$L ones understand that of remains are not banned wlmm no days Mvematlon,
Fine vise Cremalory may dlgass of they rtmalne In
an memle manner. such as lry smlYmw. rewwarm.mn
evao
CREMATION CONTNNERAIRN
enswei ONE other measure)
�An um to be used as a wManrer far My cremated awards;has been purcha%M1om M.B. Khmer Funeral Wane
and is Penney as lollmn: Mackenzie Cultured ends
IMg wuanum set if me um is and small toms the snore tRmwd reasons, an eda2onM Nor demands they W lra mrdkN«y.
oR-
MumYmm Wrtl . IM/e uMeleleltl tivh tlrw unY Wrcheees oroYrervAx pmvExl
wnemlewcrememry wa pace they contended remains In
rw..ac..w.w
a rga Ympmry nenialnp for dalivery.
This AUTorindon Foam was prmWent by Slatternly A.Giman was executed at
M.B. Ajmer Fumrel Home
rrw..um..x.M
51 Broadway, ran Edward NY 12N20
and is signed by the funeral director as wNass to its execution mm qua
i he"areired a unimpaired why of Oi$AUMormatlon Form.
The penonfe)IdantlOed below Ides this tenon st In control W dispctltron,who by aIgn Ing Nis Aullwrhefbn Farm.sdngsl
W Me assume and complebnss 0 Me Information contalned In May AuModaaWn Form and I sNarbgat the forspol np.
Slpmd MY Tely Y of August gg RO . JlA�
Sben A..k �� AC
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Sapf.enreA Gilman b 1 �
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14163 verwawmrvemu
r mT sera SYnley Rate
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DOS-18i(Rev. Di Pa}3d9