Atwell, Richard Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745.4476
FUNERAL HOME: �I,(L[Q,- _
..___. RETURN TIME
DATE A TIME REMAINS ARRIVED AT CREMATORY:
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
een 9n�_. ---- — --
NAME: ..__ raafiRD _ QTA" _CASE R _ oz
TYPE OF CONTAINER: _
PLACE OF DEATH: �Wp e,t &_y_�,- + �a - 1Iy ,tin
ESTIMATED WEIGHT OF REMAINSS—S CONTAINER II(O Uy
PLACEDIN HOLD:
PLACED IN REFRIGERATION: _ _ T nH
DATE OF CREMATION: Xg-zozf)TIME STARTED: ' TIME COMPLETED:
PLACED IN RETORT: �— _. _MOVED:
RETORT Y IN WHICH REMAINS WERE CREMATED: , 6 F (r
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 40 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SHALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
ASIR .
Oapitmw Yen, fob
�N DIVISION OF rMUMIazeWOAK p f
A one Raze
^
Cemeteries 99 onhir°e .to
Ali Nor mot
Authorization for Cremation and Disposition
This Authorization Form must be complebtl and signal p arW delivery of MMWM forumtllun.
Date: oalo, 'l n Number jot
CremWory Name: Pine View Crernatmry
Quaker Rini. Oueenabury, NY 12804 518-0<41-A.O]
A00rem: phew,
CREMATION IS AN IRREVERSIStf AND FINAL PROCESS.
Chromium is comand out by p1ol the anyolne of the le2asel and Me cerlinar holding Me remains into a Ptvnation mail were
they are subjected!to inlmse beat and flame. no Mat and Rama will l ncinmab and consume everything except bore also metal.
whichanaliMWwill MIaROM cmmaflon.
Following venation, the crematory will take personable 9ROrb W summer all of the owners and Mher metal from the operation
chamber, but shame minimal dust and rmiEue will ILLNy be IM behind The uemeloy will septum e 'modersol and foreign mateNl hom
the remains aM Meimal l and foreign material will be deschal of as suquied by law The vemaled pemana willM Montreal
su pulve re into amen prw[rB anded m. Cremated into a designated another or u Cnated remain$smal lry am Nick l moral no
single fragment in, recommends se sWN lEmw.
OPENING OF THE CONTAINER
The cematory may only open Me mnbiner hi the unSRmated human remains in Iimlted uwmstanes, rude as to museum the
Islander of de dar W enure Met no normal is small which might injure emplwem or damage the vamalory demsell If
human rename am fti and in a ronblMr whlrh is nthsuihble her cnmauon Bush a$Ceremonial or model mMt the
ry win retain,let Mem re .ln M shovel uiM1 into a sbN names er Mwre Iommgb the remains. The risen
peng of a
mmWo mmainer or the transferor named a remains will he NatuMd More a rilnss and will be delta In powers width dignity and reyect.
IDENTIFICATION OF DECEASED 1
Name of De pawl RGt1Orr4 Atwell MarrallichusuLil
ust Known Adalwas. I`Fb Big eft Rel Intl' IAK ley t2sl+1
Plareol R aeree
Sea'. xM OF Agr:_La_ OOR: o1128/ 1� 057 DeleofOMn 06( lJ o2Cl Esamed gar l: l40
Demriplon M maskeuwntainer in which R m sell betlelNarea.
M o IA I&MIC cnr,klaomna Cr@+a$OIltyn coarreabi no lyr r of
PERSON IN CONTROH.OF DISPOSIIIOX
(Pnsol in banner Wasphigher gWW ONE arm MbwvXU
I amNJe an,to denigrated apem W Me usua d downgraded In a will a woman in&mmenl eaecNed pursuant W Putek
HmM tam Setlim 42ol.
O
Vora have re,knowf¢lgw Mat the demand seasonal a when nmmmem purwant b Pi Heel dew Sel4201 era
ring Iiraeln M Me Madames N ha a her normal and Why an,Me PersmnU)cuing promy under Pubic Heafth Law
se zat aMlvr Me light to zearsommon of Me remain m Me decrease. Ayl�um ethnolp he the W r dis a9
rol
R chard R1
DOS489114 flew. U115) Page 1 of 3
Authorization for Cremation and Disposition
(LtiWa Mbwmg)
INJa uMeWaNMaI If Ne remains are mil Wlmetl Mlnln 12U tlays o(uemaAM,
PI ew Cremakry
t eMneM may tlbpose of Ne remain in
rwasan relievable manner such as by Manses
CREMATION CONTMNEWORN
@jGa(ONE offers M1HImMIg)
An win to be "Ad as a container for Me dismissed rental has been purchased Mm
and is asserted as follows
Loss unaeMane Nut if the am at red meu W Mw the mAre aemeletl remains an additional rails deal my W wMfir dMiuery.
-OR.
M um is Me y&purchased. IhVe understand May it no am is WThasad or OMmtise small
e View CremaWry
will place Me aemNea remimree it
e raid temporary container for di
This Aemone m Form adds pmaded by Patricia Miller "a eaa+ded al
Miller Funeral Home ir..Ma...o.w..
6W NY5 We. ID. Indian sake. NY 13843
and is agreed by,the furrtml career as wal to As Austrian 1
INJe have ra0aved a Wmgered dopy N Arm AUNwiaeXm Form.
The perMpl McMftd below Ware the peraanle)W control of dispoei4on, wM M signing the AAmortization Form, walA
to the accuracy said cpnpMbnaae 0 Me hrtor on caMelnee In Me AudyNmatlm Fonn and subancNs)Me foregoin0,
S�ig1re' d MIS to day �day ui .20 20
�L XTcn AQJ,, S Qn
9a�M� kA In d r Lri-i Kt AA ISµ
13
'raw.irweaws, sawn,
MATINIMI
Paiman M oM.vwrti �N
PeGee Miller
11085
OO$-18� f(Rev. 08115) Mai
Authorization for Cremation and Disposition
(in ff thorn fey nor demand
Sunni oesomption 6T9
QW nIn
1. A pesos assignment in wrmy Wrsua to Public Health M Law eOn/201(3);
2 The sumWng spouse',
Y. The$passing domestic Penner
a. Are,Summit Ulm elehtceo years of age or deer:
a. A sunrMng pared',
E. Ammnngwrong eighteen years or age or Peer
S. Alaw IIY epWiMeh grara'unl
G A"pa msl e9hleen years Of age or older added to share In Me estate and wTO Wme cbsesun relammsmp to Me aecam1
8. A duly appointed fiduciary Of the estate
B. Adam Mend Or reledive who has executed a whamstarment purmanHO Pu dic Health Law secton{]01(7J:
10. A UiN final officer Of a wanly IX a pi adminiummor appointed announce to the dampener 5 Coun PrKMure Act
100. Any Other perecn wM IS acting on behalf 0 the deRasad ads wM has executed a equal stehmrt comment b Pudic Hmhh
leH Smbn azol(n_
(s' 91A4 THREE aMe kWrving)
61 a
MASS Mmby alrum that Me body of the demands does not concern a battery, ha pad. power call, dioaUve imp4nd,
or ibepive dens and Mad any such makeraia were remcved pdorto the axeNpon of Mls Autlrorizadan Form. Failumto o"
Mere Items prior by cnmalion mry result In ham UP Me crematory and nemabn penonnal.
Pat Miller
I aMrm that IneM1UNons have been given to
dam they reseal If any personal demands or Other thing a value w Oany person gnus below or eM family member the
Pine Mew Crematory,
dewawd mn mto wrveNe.
Is cat responsible for remwn of der omnal Sam from Me mnc finer or%in the remains of dec ai Pomona]Xeme left in has
wnbl me per men Me remairm wgl M d tmyed by Mar cremation plcmps and carom M reWevad albr c adore.
Pine New Cmmaery
MW hereby auModu
r�wrnrwmu
slab dam remains of Me depend.
FINAL DISPOSITION
The Pog eWhor¢ed to re we the vmated remains sure demised fiem Me opntmry Is
Mille Funeral Home
Name;
Areas 0357 WS Has ao, IMen Oka.W 1281 StB81S 0011
Phwp'
The aas nemegd remains mainstream!MI M diapned bllmn:
bu(iol 1n Cedar R1Ver CeMCAT4
If for Crnn therm named abuse done Pon We po icon 0 the uamadal mmrm,
lumerx"s is euMV¢Bd to give�ws Iof
Me remain to Miller Funeral Home by dales
fu+vrsviww
In pawn orbs mOIN«W mad.
FichnTd fl+wcn
s.
DOS-1msgRrv. Iterlsl Page zaa