Shepler, Robert J. Pine View Cemetery 8 Crematorium
Quaker Road
Queensbury, NY 11804
(518) 745-4477 Or (51 a) 745-4476
FUNERAL ROME: alEVpy�.
-----------"`R+_--...—.-.__. RETURN TIME-
DATE 8 TIME REMAINS ARRIVED AT CREMATORY: _-_ P)] b 2'EPAI
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAIN&
NAME: OEE;Y/F SnbYl
�/
TYPE OF CONTAINER: TIM U 4)hl A ( +.
jut,` �R1hi_
PLACE OF DEATH: ,�f�. __-((LSL__RF�Q�_I1APR,fQ P� iTplr•
ESTIMATED WEIGHT OF REMAINS S CONTAINER
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATIIO�N':( B-0-gew
TIME STARTED; ,_/ 9- TIME COMPLETED: 9?z
PLACED IN RETORT; __MOVED: ��97
RETORTNINWHICH REMAINS WERE CREMATED: A �[: �
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: TNe cnvngT:OR LOG SHALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
NeW cot Sure
dlwmment a Stare
IiWYORK I Division of °MN°"r,C CEMUERIM
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SrarEar one
0PPO0.1°"'TM" Cemeteries 99W111l19°n seen"`
Ad ens,NY 122MAMOI
ore'.1518445"G 36
WIMMOSAnds,
Authorization for Cremation and Disposition
nor Autlwnn Form must the compbbtl and slgroE pier to"NOT of remsins tar crematiar.
Date: 08108I2020 Number R'i
Ommmory Name: pine Mew Crearrul Address: 21 Quaker Rd., Queens Wu 04 P ll NY 128nOne: Yc -hf-a 1
CREI MN 19 aft IRREVERSIBLE AND FINAL PR°CEsi
CremNian b urtxi cN by comes the remains of the de and Vs¢ Inx noting Me remains Into a u on Wmberwnem
they are subjected IN intense heat and Mme TM best and flame will lrslrsnb and consume OVOry lrrg exceed own*am r 1.
wagon are all that with be left Bear cssnaeon.
FaYanng cremation, Me creme will Mks Premiums eflorleW remove all WIn$remains and Oman material from Me cremator
chamber, but wine minimal dust and residue will likely neIM behind. Themmabrywillsepamlelctl l& MeignmN alfram
tin remsins and the IntldeMal and Foreign material will be dapsad of as repuirow by hew. Than aemaW reams WII be m 8nkally
pu venml into small proms and Placed into a dasgnated communist or um. Cremated Min Senanlly an puMX allM
single fmgmaM is racognWg as lensua.
OPENING OF THE CONTAINER
TM comatery,may only open the Wntelner noting Me unSRmated human remains In limbo Cnwn nma, Such as to confiirm the
ideMM oft"detteuN into ensure that no materal Ia focused winch might"June employees Of damage Me uemelory pmpeM_ N
human remains are delivered In a comminerwltlth Is not suitable Wr crematmer such as wr n4l or nnYl caskM Me
constant will require Mat Ma ramains be moved into a suitable canbinerb m It ecCepas Me main. Theepenirgafa
mndmer order transfer or removal W remains all be conducted bebre a witness and will he done in prtuery, wig dgndYand repttt
IDENTIFICAINCHIN OFDECEASED
Nam dm as : R their Sherypeor me" s s. Mantled
head anon Addreu: 496B Hill Road, Warrenebuing, NY 12885
plamm Dead: Q msaseds Residence, 496 Bowen Hill Road, Warrensburg, NY 12885
Now: ® tA ❑F Age: 66 Dog'. 1212811951 wted DeaM: 08/ 1/2020 Eaemmedweiag. 170
Deeaiptlon mmN wnuiner in wing remains with MINGe .
Florence Casket deluxe container
(Fermt(s)M mnbol of mTsea r Marcc°NE W Me NNwMgI
I a are the external agent of Me demeeN desgnewdin a will or written I ransomer emMed Mrmnt W PubEC
Nemi Law Sm4cn 4201.
-0R-
PWIehwenoknowledga Mm Medemnsedexertedawritlen In5Wme WrauaMWPubl4H"Ithtaw Sedron4201cra
WOI6nWining someone Writhe diapol of his or her remains and IMe are Me person s)having answer under Public HeeMn Law
SmOM 42n1 and Nw the nomic audorium cremation more remains of tin dowabd. kkylOurr ormhlpW the dwca was
blpx
Robed J. 6M1epler
DOB-ISWf(Rev. 0V20) Fai l3
Authorization for Cremation and Disposition
(i ad mNelldcemw)
Numaxm? DeecnWfon'.Surviving Spoi
t. Aperson designated in writing pursuant to Public HeaNn Lew 5vAm 42f)i
2. The VVNng spouse:
U. The surviving domeeac cancer
]. AN surviving onlm eighteen yaes W a"or older;
4. AsurvMng parent
& A survai Sibliig eighteen Y89M M age or oltler',
S. A bwully appointee guaMlan',
T. My pemonss)egMeenyears W age or offer entitled to antra N the estate and who was detest in rNaliMahlp M Me da[ea«a:
& A only appoiMea fiduciary or Me wbail
9. Ado«brand or relative who has defense a amain abtemem pursuant N Public Health Lav SegiM 4201(7)I
10, A chiafiaml officer of a county or a Wblw administrator appeintW pursuant to this Surtogste'a Court Pmmoure aq
too. Any corer Porsm who is Voting car behalf of Me eem«ed and who has executed a written statement punnuad W Public hwhm
Law sent42O1(7)
MagglaAu n1l✓Ne knowing)
w Mehereby aRum that Me body of Ne Mmesed have rKK Pardin a battery battery « Ni«II, rWi«ctiw lmi
orradioetlNe device and that any such metene6were remrvRa metric the exewtion WNISAUMpIrttl Form. Failuret9! me
Meae Hems prior«cremation may muN In harm W me Newell antl cremstary ryraonrwl.
k Ali affirm that Instructions here been given to DDVid Alexander
regarding Me removal W any parwnal pmpaM of elver thing W Plead which any peron sill iig below or any family mamban of toe
dedaased wish«to pr«erve. Pine View Crematch
m nil reaponaiMe air Ne removal of pereonel iYema kom Ne wmairerafiom tM rema'me W Va Mceesetl. Pereorul Hams Ica in tM
mnwmr orwmr N.rem.tm will be a«trorW air M.crem.ann proc«. .na mnWt m md«ed emr cnm.ben.
(^" viva nanbv auMama Pine View Crematory
rocrenrab me remalm W Me dac«see.
unimal OPTIONAL)
UM WON auNarl«tlre named Nneral anchor provide air delivery M and cremation by an ammi
mamry, it aeari necessary In Me domain of Me wmral anchor.and to amend this form W pmvmeer d e cerra name hod
seeress W.adn .IMmm nrem.fory.
FINAL DMIKSrtmH
The"men authorrinal W werwe Me nemNW remains W the aemaaW M1CT the nMntcry le.
Nana'.Alexander-Baker Funeral Home, David Alexander
Arun«; SW9 Main Street Wavensburp NV 12885 Pbem: (518) 623-2055
The as Wrem«a of tla«a«d wn be dispmM d«folWws:
Return to (amily
Hfs any re.«n 1M Itsraon named above does mothers pmseve'wn WMecem remam.
Pine View Crematory Is eulnonmeNyre poe««end
Na remains Alexander-Baker Funeral Home bvee9vsry
psrrwnrrrw
in mrwn orbs reeiaairW mall. RobOrt J. SMPIer
bananas
DOS-1 Knof I6ev. M201 PgTa Pala
Authorization for Cremation and Disposltion
fb�ate forearm
//�mwe understand Me ifthe remains am net claimed wiri tea days 0v on.
Pine Vase Crematory, mwdlsW afthemmdnsin
m...ac...rw
an universities terms.such as a by snaring, e
CREY ON COKMNEMRN
(mOwEWtlwmpl Alexander-Baker Funeral
_�M um ro M uaM a e nMaiarbrNe cnmetM remains as teen purcheaetl M1cm u__e
md 'u dexribN ealdWn-
W/e urAerebM Met tlMe un IsbOamell b bpgiMaNnuematM remane.an MdWOnal rgp aoNew may a uW brntliwry.
M um la nNyN WrtliaassE. InYe uMerWMMtl X ro um®Wr llesed proMeonae prOrNW
Pine View Cametory will plane me cremated remains In
Possession
a red temporary container for tlNlvtly.
This AurMtlaetlon Farm was provided try David Alexander was everted at
muregral Hlom
AlexerMar-Baker Funeral Home
U09 Main Street, WarrensWre NY 12885
and is eioned by the mnwel director an winners M Its treasurer.
I We have received a completed copy of thla AUNOtlaaOan Form.
Tna presents) identified belax blare Me parands) In contrat of dlspasXb .grow by sgnlnp MM Astronomical Form,a AS)
to Me accuracy and continental of the shoemaker mnfalM In this Autlmsinaion Farm and auMOXnb)Me MpWOg.
Signed this 3rd aya August ,20 20 C
Susan Sheeler �. E1,. 0 W-p4.✓
a�
496 Bowen Hill Road Walrenaburg NY 12885
A.
stslorivhadrai Assisi
W EM:
David Alexander
10034 ,wu>aeaam
Robed J. Shepler
vrwo.�
OOS-19941(Re, 04am Rgelm3