Brown, Sheryl L Pine View Cemetery & Crematorium
Quaker Road
Queensburyl NV 12804
(518) 745-4477 or (518) 745.4476
FUNERAL HOME: Fk.Y[
RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY:
2
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
NAME:
TYPE OF CONTAINER:
PLACE OF DEATH:
ESTIMATED WEIGHT OF REMAINS & CONTAINER IjS 1{.r
PLACED IN HOLD:
PLACED IN REFRIGERATION: _ _ 2:0
DATE OF CREMATIOW B-B-ZoZO _
TIME STARTED: TIME COMPLETED: O
PLACED IN RETORT: ---MOVE[
RETORT N IN WHICH REMAINS WERE CREMATED: 1a&vlLr p n4 -T
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 40 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE:THe cee AAT:ON LOG SHALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
Dewrtmenterk San,
NTFORK pIVI510fl Of orvrsroN OFCEMErERIEs
STRFwOu Ore Commerce Pan
oce
"" Cemeteries NW11,191,1AIII
TPep ne:t51844ham a
Authorization for Cremation and Disposition
This AUMw/ntlon Form must the comple and signed pXOrm Oellvan Ofmmaim NrClernaYon.
Date: � -1 17.0 ZO Number: Q6'
Cmm" him.: Pin View Crete m
Quaker Raise.Owmsbury, NY 128U 518-741
Address Phone:
CREMATION 1e AN IRREVERSIBLE AND FINAL PROCESS.
Cremation is earned put by pacing Me remains ofthe dex and Me mnlamer holding the parishes into a cremation chamber where
Neyaresubletied W1Menaeheelandflame. The Mat aped flarri 111 Incinerate add consume w Ming es<ept bone and nrtla1,
which are all that wilt bs OR Other cmna0on.
Following oemetion,the uemaWry NO take anual efloM W remise all of 1M remains and older award him tie Crem M
cham[m, but some minimal dust and ressim wil hkpy he left drum The channel will separate small and foregn maser it M1Om
Me remems and themcdental and merge mned4l will M dlgwagram required by law. The uemaled remand still be mxhwm*
pulvn¢ed Into small pews and placed Into a designated mnbiner or um. CMoWmmalnsgenerallyampulwri U"In0
single firemen is recognizable as sMiwl dvue.
OPENING OF THE CONTAINER
The crematory may only open the MWiner handing the unuem sled human remains in limited dmamstanss,stKh as to radial tM
identify Of the partia d or to ensure this no maledal Is induced which might injure emPloytts Or damage the(mmemory omwillH
human remains are delivered in a container which Is not suitable for cremaEOn such as ceremonal or rental weM4 Me
Crionnafterk will require that Me remains the moved Into a suitable conbiwr Were It accepts the remain. The opining of a
cominerOr the transfer or removal of remains WA be mndWM mucre a witness and WII M done in mr acy with dignify and wanted.
IDENTIFICATION OF fDECEASED
Name aft Decimal. `li`�/111 L Drokiln Mfti BbtU$, di me
lawwmamnndam: lD29 RFc 9f\( Iladk� t`N_ 17G>�S
PlawWowsh MS ckn
Sex: OM ®F Age a'D DOB tpIci 1 `10 DeWaoeeM 5?�bj2�0 E,bmmm wegm:1%Z
oewip5on aueMVmMeiwr In which remain win M federal
McDonald basic cremation Container, no interior
PERSON IN CONTROL OF DISPOSITION
(PoM4(4f M cvMbpldd4wyFw, NItieIONE oIIM Mlowingf
I mNJe are Me Ce¢prlwed agent o1 Me d%based designated a a will aweaken Iannin ens vented pumuamm PUMIC
HNIN Law$%lion Q01.
-0R-�
J_ INJe have no knowledge Rat the dew W BMYtured a wdMn Instrument happened M PILL&Heats Law Sedion 4201 cr a
well containing directions her the diswaMon of his or Mr remains and IM9 are Me wsson(s)hating pdonty under Public Length Law
Simon Add and have Me rght to suNor¢e vmution of Me remains W to d ased. Mylourre onshlp W Me Asomfud Is as
"Iq " I L Bvoa�
a�—
OOS.16g&t(Rev. 08/15) Page 1 of 3
Qutherization for Cremation and Disposition
( flee WlbwYeg)
R —✓ less,underYaM led if Me remands we M Gained wihm 130 nays m uemmlOn
,
AYew Creamery
ma.. own may cleared at he remeinsi
an incerevare manner aucti as by a® ng.
CREMATION CONTAINEWORN
Saaqp(ONE a Me M1Mbrnrg)
An Ar W W dead as a conralndb he pem91W!echoed has Lean purclaw]from
and is nemnLen as Mlowe:
Votes understand Min if Me um Is Wa smell W M1OM he @man diamamn additional, an additional age!¢^ashen may be uW Aw dellvi
-ORR,--�
1pv An did M yet WmNaaW Wha)a understand rMl 0 no um is mrchased or oMs mpmrtded
Plne Wry Cremalay,
Mnnnss"w wall handle Me dismayed remolds in
a lard temporary consider Wr deffery.
Patricia Miller
This AUNd%ation Seem was pmea ed by was executed at
Brewer Funeral Home, Inc.
3a Cfrurcti St, lake Li¢eme, Nyl3ese
and b smell by the Nieral nketld as wlmesa W its modernism
mVe lave reativen a compared way of this AUMorinniien Farm.
hat remnlsl ldsnNded Mi Ii Me rerson(s)in wnbol W disposition,wed by signing Mis Autlwnasticn Fame, rtbsys)
bae eccuspy and wmplaYnsss of Me abominable conWned In Min AUMarizNon Form and authorrm(gtla Anneaing.
algrpd MM delay . M 2D
_izas R 4N !- 01,4 p'N I'Ms
ssasi� Seeder
WITNESS:
Pamen ITMlller Ifl1�0afl• •BIBt!
u12455 rw+'swuxw e wow
OOS10N f(Rev_OagM Page 303
Authorization for Cremation and Disposition
pond M1mm ma/ enact ��11 1
NurMel:ga partied lan: Cry 'n O E±I
1. APHxn cadmium lnwrXngp[vmnMm Pubbc Heats law$anion y]Ot(3);
2 They crueiving spouse,
21 The aumwing dorsal paMer
3, m AA^y ^ring child eighteen years Of age Or deer4. ;
5. A s g pdi
urvlri
6. A4rismi amendedsharp optical
OM1men Years Mage or annual
L Any ceron(a) eghteenygrearAnd
6. A duNimpro Metl model name estak:aoer entmm lo[Iraremrlre etlelgaM wTa ir/ere tlo¢eY in reiatlmanipm maegn¢aq 6. Achat r or officer
Fed who has meculed a wrlllen 9armint pursuing to Pi Healed Law SeNin@O1 p):
pass Any otherMason"a
a courry or a publ'm administrator apparent parent to Me Surfaced,Courl PrnCeeun AP,
$e[Ton 4201 Bois red, on talM Me docia a and wed has veeutee a wrMen aatemenl come lm Pobhc Heats
?Mill� REEMeM byaaery)
/ '— MAN he"afimr Met the Cody M Me ettba¢ed does am mndin a battery. Faddy Park, pgyar xil. Win ows,Midland
Of ran'w device and On any such mmelmd were removed prior to the wewtmn of Me Au Norhatlm Form. Failum to mnW
M./W tteme gbrmchamber may molt In lrenem Ma caememry and ChaChannelna pamorfryl,
1� —R—� Mew Mi Mat admit it have bean Patrry Will
gNan ro
rWNirg led removal of any personal PmMmY W Other Mine Mways which any peram Ma^r erg m^'Pine Vr Crerremry beaaMdmily member NMe
dare.xe walrea In ya¢ern.
is net remondlme mr Me removal Of personal ikm¢1mm Me car amer oraorn ilia remain[of Me ae¢axe. P.remal items lm m Ma
ro/n/m�im wM rolMarer bag^ain be MYmm
Miami Me antspro[ue add banned be mMaved again cremation.
r/� IM'e Mmby scandal Pine Mew Cremmary
ro.r.m.a.r.r
to cmemd tea nine im M Ma awea.ea.
FIX
The pea¢^^aNNr W Bxive Me[nmated reghwas arms dec tape they oenulp)•i¢.
Name, Older Funeral Hcme, Inc.
20 CM1urM Sp, Lyra Luzema, NY 12&8
Addreu: Panne 516�b2TM
The ogrede remeim MdWaep Mil be Gapyed of as roll
rc*wr t +o Paml
xraaM rmpn the cexn tamed added deals rpm pled rye¢ w a Me cremead reMane.
%ne Yew Lrenalory
and mm maro
Brewer Funs Mail hi Is e morided to give pm¢ewa^a
rn.....,r.r,.x evadae[wy
in perean or M repwred mall.
�I�f(Near pent
Pece2M3