Brock,Jill M. (2) Pine View Cemetery $ Crematorium
Quaker Road
Queensbury, NY 12884
(518) 745-4477 or (518) 745.4476
FUNERAL XOME: a ;.4DaV^ Qo
��.--._... RETURN TIME: _
11L-
DATEB TIME REMAINS ARRIVED AT CREMATORY: ,_ _ M.
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING
�N a
K CASEpTYPE OF CONTAINER: __ lh�
��J�
PLACE OF DEATH: --- IYli6 " '- — - --
��n�L-__t<°AP n n7w
---------------
ESTIMATED WRIGHT OF REMAINS 8 CONTAINER-___ �-_
PLACED
PIgCED IN HOLD; --`�--�
PLACID IN REFRIGERATION;
DATE OF CREMATION;
jy,
TIME STARTED: I���TIME COMPLETED: —
PLACED IN RETORT: __JL_ _MOVED: ____ Ito pry
RETORT p IN WHICH REMAINS WERE CREMATED: PA f^
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY;
NOTE: THE OSEMRnoN LOG SHALL BE RETAINED IN THE PERMANENT FILE OF THE CRAmATDRT.
Nosy
mention
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Tnu ANnorizatlon Fa^^mast IN Companies
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0810712020 Drem co Pwm.-
NM,a: Pine Vle`° NYNy 12804
puce Idoacrema �
Onma sou
pydleaa: 2l Qua ker RJ- esa nan noklno ha remains N 1,
BSIBLE PxO FIxF.LF inihissrise 80b erau and comma evezyMng aside
M IB AN oxRERE a0yq remains nptandaame'�'I Isom the cremafwn
GRem PTO ^bY M° Bandfianm
L �wEN Isi mnse* uon. ^'Oen edzed anUlm
Im a reman scztma�m
remevs w,raign matet�sl ro
atry�eke rensoroul°eAo toN w� 1l be mactanlwlly
M°yert mbeir vdN noel m1aR set mired by New.The uamaud
F�yxirg oum�nMmiaw"i r8e�an"likeninal Yl ea .ourprma emmama remlaa 0e^°ra0yyJ 'm�Wle
brambec bal acme edenol an dump
ne Mei dparre mM aaealg�t
Me remavier maNlNeceBBsb1 as swaso Ysa INnaBe atwm%Iances, suN asM concern Ines
'mlvanzeA ty pEOOn remamB in tl mega me crematory goPardi n
{n01a na9m°n PIH a nddM the on.creannagntinryreemdnable rendin for nmal aask6 the
y INO OF on,main the c°^u°t oo random h Iencloso cnmabarr sm a°ca MOnmeim. eminerThe m arelwem-
toNuayBd toemm �µ outa amake'Iner barren will be done in ptwary.wdh dg^Man
Th°m r,derYof the ownedOliverea In a ChadNlnM'xh�l a„m¢d lam anemone
°
wry win mwre that ma mrmmr hemw
humanmmamaimono remover of remBimw+N t»mn ataroa'. Married
awmamerwtheam -
F1LP N , Allld� NY N
E
e Jill M� F#0
Nem°of Ibae'SP - -ad Athol, NY 4610
1136 DanmoulhR bb 13f
Address esldence. 1136 Dart
Last Moen DecaaseE53 0Death. OBI EBEmauaweig
Mace Nlxarrt 1J1121196a
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area In a"it orwMMn in9rumenl resoundPunmam to
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anfle
medonave nok Ma rat moron
u aeo-eagonz or n n nza modules JiII M. Brock
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IWlowa:
Authorintion for Cremation and Disposition
ftnwrthom Ile Naf NWw)
Numbm; 2 Desaiptlon: urvivin Souse
1. A panel designated In whiling pursuant to Podic Room lax erosion 420113)I
2. ne aurvMng annual;
2m. The suMviag eamestic Pasco:
1. Any survival chile eighteen yearn W age or oleo
a. AsuMmng parent
5. A surviving sibling egM1men years W age or older:
5, Alewfuly appointed guartllan:
F. My persona)eighteen yeah of age or older ended to share in Me eMreantl wlio team deficits school to Wa de¢e
a. A duty appointed fiduciary IN the a WW,
9. A Goer Mend a relative who has assumedwam tod a women stMmmt por Pubic pared Law Setion42019).
10. A diiN fical doctor of a mangy or a public administrator apnairded punuanl W Me SunogM a Could Praedure Ad:
MR. My Mar Paton who As acting an crown of Me deceal and who has Accord a women agreement puruant M Public He6M
Law Section 4201 of
gglact ALL THREE of Me rolbwlagl
Men Novel affirm Met the body of or dxaaua does nMwnnm a dMAm, badly peak power call machines Imp se
orra ioarove device and that any soon assembly were removed pear W Me sseral of this AWhwaa Form. Ftllure W nmWG
/)Mass Items prior to mmNon may result in harm to god creme and mmMry petonnae.
Inch affirm that imandroronw have been given to Lyjyl()o-ulexxaander
gamir r Me removal of any Personal prone w or other MIN of value which any "man sgoing arl a arty family Margaret of Me
re
Pine Vlew m Create
comeacea wishes to preserve. µan
is nm responsible for the removal n retaaal Items hove Me runnMm of Ica remains orate eaceaaea. centered nsnre life In the
moral r With the remains will ber destroyed by the emanation process and cannot W restdevee after emMtlon.
—. v uwanereby aWhorize Pine VIEW Cmmry
^oi
�w Me W cremareew remamaw Me e.un.e.
Nadgl ovnorvau
mare hereby authoem the named funeral director to provide ror delivery W and cremation by an alternate
metary. If deemed i "saay in the opinion of she funeral diremr,and Wamend tnteeorm to provide the correct name and
address of Such awmaW cramaWq
FINAL DISPOSITION
TMpet Mohre]W Maiur Me mmatea remains of the removed limn the CRma is:
Name:Alexander-Baker Funeral Home, David Alexander
Andress: 3WIS Mean Street, Warrensburg, NY 12885 _Phone: (518)823-2W5
The amended remaau N d was will be disposed Of es l kwVS:
Relum W famil
If Wa"team eat"mnnamed ague does not take possession of the a mo Marina.
Pings Uew Crematlxy sewthmaea W give pos6agan of
Alexander-Baker Furterel Home by aetivary
there 5to Irwarwr.n.v.r
In perm an My regiMe veal. JiI M. Brack puµwi
Page 2 of 3
WO IIHRV(Rev. CAM)
Authoriutlon for Cremation and Disposition
ba3lm�� m�{emlawmm
IMY unaarstena Met ifft remora are not uaimM witbm txo days of cremation,
Pinel4ew Crmatory may dispose of Me«mams In
an l merweii manner. Such as l ry ananaHg Warm"
CREl1 ON CONTR NEMRN
(IndaI ONE miss Ast ommi
Alexander-baker Funeral
M um to be used as a container lm Me unmated remains has been puchaeea from u.....e
end is duuibetl as follows
Asia undemWd Mat It the um a too small to hold the whom aerated matins.an adddhonel No container may be and for deivery.
I*M um 'q net yet purtlwed INJe understand Ntltlmumu northwest uotMiw'we provided
Pine View Crematory and plea for cremated remains,In
a rgid temporary container for delivery. �xmnunmmmT
The PUNo/ludOn Form was sniveled by David Alexander _was exeaWed at
Alexander-Baker Furhral Home
WN Main Boosted,Ware sWrg NY 12885
and Is Same by two f nnind d re to as witness to its erecNion.
INS raw m ivad a completed copy,of am Audiotlieaon Form.
no MmoMsl MoMifi d bMow Ialare the peQoMs)In control of imposition.who by signing this ANhonzation Form, amsgsl
W they accuncy aM campiabneee of the Infomution contained in MIS AUN zagm FOM aM ar orl*si the Removing.
Sgnad Me Rh aeY of August , xg 20 /1 ,a
Bryan J. Brock
1138 Dartmoufh Ro , Agra, NY 12810
Ski
MNE
David Alexander
10CI
Jill M. Brock
tmwc..ea
30S1808f(Rev. WN) Pgp3 03