Lombardo, Nevaeh Pine View Cemetery & Crematorium
Quaker Road
Queensburyl NY 12804
(51 a) 745-4477 or (518) 745-4476
FUNERAL Nome:
- ---- - __ , RETURN TIME:
GATE 8 TIME REMAINS ARRIVED AT CREMATORY:
R LVAN
NAME OF FUNERAL DIRECTOR OR REGRIGTEREO RESIDENT OELIVEflINO REMAINS:
NAME: .... ._.___ _
NF.IINE �_ wri yl�`Y.L) _CASE R _ . q� _H�
TYPE OF CONTAINER: t( b�N
PLACE OF DEATH:
ESTIMATED WEIGHT OF REMAINS S CONTAINER_
PLACED IN HOLD: _
PLACED IN REFRIGERATION:
DATE OF CREMATION:� 1
TIME STARTED: _ 'IO An__TIME COMPLETEDa y-Arl
PLACED IN RETORT: 1. 36 11 _MOVED: __pp_ I0."DryP qry
RETORT 0IN WHICH REMAINS WERE CREMATED:
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN AE HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SMALL HE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
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Authorization for Cremation and Disposition
This AU oMm6m TOM must be completed and slpMd prior b MINery of MMIM ter PerMml.
Dar 081OW2020 Number 101
CremNory Nam Mine Memory GRr1181onum
Amosa51 Quaker Road, Queensbury NV 12804 F1xm: (518)745-441]
CREIMTOX In AN IRREVERSIBLE PM FIH/,L FROCEBB.
Cnmetm is mimed cut by heart Me moiM d Me demasetl ON Ins commerce hop'aq Me remai hi ink a cremation chamber Where
tley are subpcted to Intense beat awl Nme. The Mal ON xama win imam Bawl Museum aaeryMma accept bons and meml,
whim am an oust wJl M left Offer cremaxon.
Fo ceri arematbn the uemakry will taus maeanaae editors remove ON W Me remain^and am,mahnal tmm tare pemated
clamber. bid some minimal dust and rescue wall likely M Ins behind. TM consul all sesame common and tnreipn marefal from
Me hansom and see boMnkl and krawn normal an M dlagvwi d as ban irml by law. They unmet^ remains Wn M matlhanimlM
pavenml into small peons am Placed into a dumgMbd "Marrs or and. CM n ins generally are pu1vmad1 ump no
single MBmant b mnnb Was sblWel Made.
OPENING OF THE CONTAINER
TM crematory may only open the container holding the unrcre whim human remains In Indeed circumstances, wU eakmrhfirm Ms
ident of the commerce orb encore that no m vets Is entlosed when might injure emp orwas or damape Me murde y postal IT
human remains amdNiver Ina conrhwrwhkh Is redoubtable ter mmatlrr such as ceremonial Or rental usFµ gw
re "will require MMthe rwmiM M moved Ink a sbbbie coMinerb m N socepb ins remains. ThegenirNae
eomeber or the 4analer or removal of means un M coMW2d Chore a wMMs awl WII be tame In terms,win dignify ens moves
oEM FCAnONOFOEGEABEO Neypg,yv
Name of Decreased Baby Lombardo Narnal stabs: Nasser Marred
taut Known Adgrgss:55 Lambert Drisse, Qunensbury, W 12804
Ran ul DMM:GIens Falls Hospital, 100 Park Si L Glens Fells, NV 12WI
sea: ON OF Age: 0 Don: OW04MM DerdD OaNM2020 Eetirratm waft
DM om ofoska =wm bwbkn Mnaim NO Meaiiamd.
Filaerboerrllaltemame Manitoulin
pERsox xCONTRDL OF 013P mON
(Ferwama)b ddntrdT rdap"w"a,�r DNE m xa mwwfry
I amwNe am Me deslpered New of Me depuM de&anated inaWil"unit^irubwxm Yo"nM Pursuant to Public
HUM taw Sa"bn 4201.
m�µ IANe have no knowledge Nut and hmMl maCNM a sudden insbumeM Pumsm k Pubic Hearth Law Swfim Q01 or
will wntaimy daealms("a hummureon of his or her remains and INre are the pwemist having Toney under Puab Hal Law
Moroccan 4201 and Nva be right immune mmat'nn dMe remains MMe eeUam. shown samura unlpW Me decrosed'a n
bllowa. ueV Ih
Baby Lombartlo
DOS-10g31(Rev. (i Paget 03
ihorintion for Cremation and Disposition
r foam Iran day at beery)
dumper I DBetnporm Summi parent
1. A Mayon designated in more pumuaritto Public HwM Luna 8edmi R01n1.
2. IRe surviving spouse:
le, ilre wrnNng eomestk Wnrwr
S. My surviving child egMeen years of age or Oder
4. AsurviNn9 went:
S. A wrvrving sibling eighteen years of age or oleer:
8. AIaN IIy accounted guardian;
). My reremps)eiMcen"am of ergs or Oder courted 0 agency,the nodded and Who 108M do In aylWonship to the eemaaedl
8. A disappointed fquWry of the imate:
9. A close Rend or rebtive who has evsutM a written statement pursuant W Public Heats lac SecOm 41
10. A clued fieal officer of a county or public administrator aMa'nlee pummist ho the Suocgele's court Procedure Ad;
19+. My other Mason wM're scrng on IxFaH 0 me detests and arm has appoted a wmarn erthrant Wrsund W Pubs:Heats
bw Section 4201p1.
(T ALL THREE Omer Mrowin9)
mL Tay code hereby emrm m+t me body acne Ogee+.Maces mlConuin a eatlerv, binary Wa, powercell,mWi++ctive lmplam.
orrMioamve dBNa eM Ihat any wch mBlBlielewere rcmowa plNrto Ue esecutonmlMe Aumwtaatlon Fps. FailureWArr o
arse tlenra prior m cremation may mum In harm W the cnmaion and neneiay pnemml.
X mL -(iv+ Me affirm over Instructions have bean green W SS hhAA. P�hllo
regarding me removal of My MWemI NOMrs or oMer King of value wNch any person agning bNdw or any army member O fire
demaaed winners to meth". Pine View Crematorium
is Mtrepnsime WrmemmMalOpersonalitemshommemO+merord memmainedmedecoded Panon.l Xwma eamm.
C ineror MinmeremainsrillI emtmyeabymacremationp moaMmnnat shaved Maraemabon.
MILL Tti lWeherebyaumorize Pine Vaew Crematorium
W cremmm.remains am.aeae..w.
(ram CacTl u
have Hereby cognomen the n.m.e wn.false WpmvWer 401vap WandcmmauonbyantlYmale
crmnlory.neeem.a n.ues+ry In m.opinionat iro r,+ne WamandthWWmrWM idemecO nameena
deems of such ahem+W Cramer
FM LDISPOSIBfON
The down
ordinances to raaiun the crammed remolds a 8e deaamd hun Muermay e:
Name:Regan Denny Stafford Funeral Home Sarah K Phild
Achieve: 53 Quaker Raed, Dueanabury, NV 12W4 Pnnc (518) 7`92-1114
Ter umaw remedy a ft aW will baaispaedawWlbxa-
riA Ia L.nmlvdri�..O� rrn ' l- C
MkraM rxwn 1M Mrtar namM Ma+e doe MI WFepvwakn a W aene4d renuFa.
Pine Yew Crematorium bau8miaee began attempted
Ow momimm RN an Denny SWITorE Funeralme Ho Wee"ny
In Minn Or M Mialnea mat. P..ww..a..w h eyaii1 Baby Lombardo
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