Kelly, William D. Pine View Cemetery & Crematorium
Quaker Road
Queensburyl NV 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: _____ „a
—ItLl --.—__ __ RETURN TIM2: ___
_.
DATE S TIME REMAINS ARRIVED AT CREMATORY:
NAME OF FUNERAL DIRECTOR OR REGRISTEREO RESIDENT DELIVERING REMAINS:
NAME: ._ U�.G(Tfyt�_..ir1/� _ C45Ep ICJ
TYPE OF CONTAINER: � ..LA ¢A C,
PLACE OF DEPITH: ,_yy__ •� `�"' -�6 > d -T+
ESTIMATED WEIGHT OF REMAINS a CONTAINER_____
PLACED IN HOLD:PLACED IN IN REFRIOGRATION:
DATE OF CREMATION- (.
TIME STARTED: ,___ p ER TIME COMPLETED:
PLACED IN RETORT: /0130ATi_MOVED: �SK�t1 I�'1Mefi 1z
RETORT A IN WHICH REMAINS WERE CREMATED: Oft
UR DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SHALL BE RETAINE. :N THE PERMANENT FILE OF Y"E CREMATORY.
.nasun m
NEW PORK Division Of ° 1O�°F �Eq
San OF
Or
°PP°t°11XM Cemeteries °_^
reeNe:Iswl a#6l
Authorization for Cremation and Disposition
TIIIs auNwlaatl Form mutl 0a mmPleleo and signed Prior to delivery at lemal ne M cAm On.
Data Au9ul S.IDA Number: q0f�
Crmnldy Nestle �wY Crenetry
Mpeve. Waller Ad.°ueer , W13BM Pie. 5147ISM'/1
CREMATION 15 AN IRREVERSIBLE AND FINAL PROCESS.
Cremation is canned Col by pacing Ibe Tema as of Me demawd all Me =minner named hie ¢mans into a chamber tlumberwMre
device Pascal mimense heal and name. TheA andnamewillmammhandansumemry ingexx Mrmandm
whim areal wtwlll be left aMr alemenan.
Fmlrm d veinal the crematory will One reasonable Aeons to remove M of My fare.....d rMtt malelal From the=rcmat",
mai but come mimmal dust and residue wit IIl be lea behind. They treatment Ad a¢puatt mWaal and cal met e..I Imm
Ito Imams all die Inadaal all fwagn manna MI the dremseE W as repaired by law n aema remain.All m meeMnkit
yNer¢M Inlr mall gemand pie¢d'nbadeagnalal coTairarwum. Cr aWmmalnsgm"lyan Wlvmlmdungln
single Fragment is m"nine as sFaaa dssue.
OPENING OF THE CONTAINER
rude cement may only open Me mmam®hndlig Ito an`aema human remains In limlled(Mmminrea an& as to nml has,
areas Whiede,mmed or to ensure that no memdal Is Mn6 mllN Min injure employee,or damage Me =rarml properly
human remans are dellvemd In a analntt whim Is not mlbble Air cmnation such as cemmmlal or moral casba,Ito
creditors will require Nat the retains be moved into a sul is comviner Celle It xcats Me romans. The opening of
mnameh or me Vanshr or removal W remama AN be mrgaded beers,,wimem all an be done in evil AM dignay all Miami
IDEN11FICATION or DECEASED
Name of.¢w.. Ver 0. KNIy scia lSbms: Wdo
"at Fricvm Morass: li Wnlee Ave. Mason Fab.Fly INS39
�of OeeM: ti SYnM Ave. Hl Fees.NY 1ID39
aw, ON Or Age 84 WE: 07105H936 Di of Eahimledvladlt 21MIEa
Contrast amNWcmleimr in Aid,remmes wf!the darvered.
ClNlegated cremation Container pine and cardbou ld
PERSON IN COMIROL OF DISPOSITION
(FMam(6)brr wad atm, sued 0.VE ag Nf
I mNle are Me deslgmtm agent Mlheotteased din mr In a All wxrlWn Mdel ermNM Wm tb FAN
Heats Law M MM,4201.
W-
K 'V More have us chwedge that tM aemeW a mml ,Anna Malaw nt Wnnt as Public direct,",UOm alol or
mM ,n,N directions air
to daW of Na e m her man, ll a lop the,am pmauAs)MON Wanly mutt Pubin H MLew
m5directionsrliona201amhaveftnMtopuNoml maltocfl re insoftl dm.,e]. WOUrrefm iPto Nedra ism
follows:
William D. Kelly
D091S9B-0(Re, 04120) Pqe 1 M3
Authorization for Cremation and Diaphimil
(InsulM1 ftRaM
NU ,3 (tayiiman Mr curvier dint,chiral remains Ape a Min
1, Aglam MSlp W In winded amount to Pude NeeM sew Bedai Q01(3):
2 TM wuviaip Mum,
than m.eaMainv dnmmdn molder:
a Mor swervind cold am meen years of aye or older.
s. Afumbi psrenl',
S. A wrvol sldltg eighteen yea of aye or obey
S. A aMully appointed maremn
]. My perwnlaj eipxteen years of eye or older tribal b Mara In Me mum am added stare Poses)In rel ShP n Me MexeM:
A duly concintde fieutrary d ton esbsl
9. Aem,Mond orreubleethic loss executed a mun atlbment immuMt by Pubar;Mum Isw Seemed 4101t])I
10. Achief cast Amer el a aunty by a pool',M moment appolnse wmuanl to the Surrwate a Caul Premium,Act
da. My other person won is added of ue of us,,urine add more Me Mmnel a wI smor ldeal b Pubs,xenon
Lee woman 4201pt.
ll ]NaEE aloe raewlnPl
dl(,. Me hereby alfam Met the body an the M keel adds owl mal a mum u"pars,power call,reepecMe m al
arv9mcNe Beam dine Malam wN matenMaware rdmvee ynronne+warMn of MlsAnlrorQanw Fwm. futonment
Noe mum prlw b nemdlm my ran M lumr to nra veld M and mandatory peson en
yi me Mm Met msnd name been were b iimtOry Murpdy omru
,,,ddy Me buoyed d any Porsorulp4arlY an army mum of mum M day person sl9rnd mum or my farad,mermf aMe
tlesarM mum,b peon,. Ph"yields,Gemelwy
o on resp`risl br,Neremoval or foaanal Items dam the denteirrer or M1wn Me remains d me model Panonal needs NO In Me
cmm r or MN Na remains mild be comment by true monarch posva and cmna be rMrbrae alter commands
ands
��ltly
r, ,Meher wth l Mine Very Cramays
w max the) ins or Ned raw,
Ilmmf oPnorvay
Nse hereby Symbol Me mmee Nneral ,honor to pmbd year y No and aemfi*n by an allamala
nernelarv,ndeemed necessary In the minion car Me Nneral Mredbr, and or armed MIS soon in Such the Parrcn name and
ad a such alfamm mremnny.
FML DMMSlnox
1M pxsgo wt Wb make theamounted!leinbm of do M1wn Me vwmtfy x.
_ M B. Kdmer Fumral X
Attitude 03(Irmater I Edeam, NY 12M pyy. 5161d] @PO
]Meer nee remains aexcuse,Sol Mdspme aotlbax
xwnPmnna ce,narr
n br er lemur db paladin nm.e came aura led my.lasaYnt a u.n.nn.d remain,
PmY Nethral seuWRM byo pswdmd
Me amine to M 9. older Fa Pense mw�snrsvf by don
in perm an by nPstmaf mal aa.+wsW nKMIy
WS.I&I(N .(Ar nun such
Authorization for Cremation and Disposition
Odkl um rNw.lny
V,V Me understand Mat Kate names en net tltime] WNe lzo dswolasmsda,
Fins vew cmreary meY diyaw ad Me maymnsat
an m,M,w,Me mina,entire 4 Mimi
caEM MNCOWMNEWUM
nm_L,r ENE Nye Mknrpl
Mum b[e used a e comment M Me crenated mmine am mean purchased M1an
W n Mounting,s Mkwn:
MeanvareM Met Kdw urn mmannWlb Md beep mane aemelM minus,an WXbW rbdav4nxnq Cs Yssdbdr!/xi.
{.Y' Mum isMMWroK®ed. V]ieuMxeYMMN ilrw unw puchivanaNvwim prorked
VapV CnaraWY will plan Me cremated remains in
a r'qd bmpaery¢Maiee MdeNwry A+s'es'sm"W
Tas Augmentation Form urea moeded by Tmothy,Murphy wu eaewretl x
M.B. Miner Funeal Nome rti�rw
V B,mmmy Fat Edwad NY 12Bm u'nram..xA
ad Is aryaM LV Me Nrartl dlrctla as'.nNo Is N essaCcn wn wem
Me have received a Completed wNNMr,ANMrtatlan Form.
iM pOsmNai WeMIKed below Ware Me pnonlsl N cbrbN N who by sign"Mls AutlrMaalAn Ferri.Y gs1
U,Me smanxi ndsaupkinent W Me Impingement asymadad In MN AuMorbeeell Fetrrland suMOM1611M Ma IN.
&prcd Mn � daiii �M .m
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