Branch, James F. Pine View Cemetery & Crematorium
Quaker Road
Queensburyl NY 12804
(518) 745-4477 or (518) 745-4476
FUNERALNOME: Q-
- `SS"- RETURN TIME: ___
DATE B TIME REMAINS ARRIVED AT CREMATORY: _ S)7Ia R
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS
NAME: .._...____?Nn BRALCI�
� CASE k _ DO
TYPE OF CONTAINER:
C� III_-�Cti111� l�vL-1-
PLACE OF DEATN: .__.__Y�(_-
ESTIMATED WEIGHT OF REMAINS B CONTAINERS 220 11
PLACED IN HOLD:
PLACED IN REFRIGERATION: __ --�
DATE OF CREMATION: _
��w, 4171w _
TIME STgRTEO: � IOjMM TIME COMPLETED: R SqH
PLACED IN RETORT.
10_SS 1M_MOVEO: --- /J,3wm �.
RETORT # IN WHICH REMAINS WERE CREMATED: �
DETAILED REASON FOR DELAY IF REMAINS WERE C
FROM TIME OF ACCEPTED DELIVERY: REMgTED ORE THAN pg HOURS
NOTE: THE CREMATION LOG SHALL OF RETAINED IN Tilt PERMANENT FILE OF THE CREMATORY.
peRmnI'll
Yuri,war,
VO0.K
o of
Me "mw OF CEmes
� Division
vo °um Cemeteries so yw;, Awl
Authorlmtlon for Cremation and Disposition
Tab Autlwrtral Form mat b wmpl@W and signed prime to engineer W n im for emn n.
Bear OBI06I2020 Nurieer: 500
Crematory Name:Pine Uew Clemat UM
AMrex:51 Quaker Road Queensbuly, NY 12804 Rune: (518)745J4P
CNELIAnON IS AN IFBEVER&BLE AND FINAL PROCESS.
Cmne(pnis merged Mby pacing taw remake M Me demaaed and Me common aadina He remains into a umrwtion rlunLvwire
tMy are sub? t to intense heal ant flame. The l end name will lnana and normal everyMing eewpl bm@ ant mile,
watch am all Mat will the IM after minion.
FoReaing cremation, the channel will take reasonable¢Bons to remove all of Me remains and inner material Mars the cremaWn
member. but Come minimal dust and voters will likely be left behind The Crematory Will aeprale lntMenbl end loregn melentl Mars
Ma remains and the Inciidenall and foreign malenal will be diswo of as reauiM by W. The vemebd remains will be macntia lly
rytvenmd into small piers and placed into a designated wnbtm or um. CramaMd mnams ae mill am Isulwdmd ungl rw
Wgle"nwrt Is recognlaabb as Martial Mems
HEXING OF THE CONTAINER
The Vessel may only such He container heard the unoemMed aumn comes in burned circumstances,such as b confirm the
doMiNofttedewawdortoensurethatnomaenalisennlosM "T might Iryumemployeeswdamage MecmmempmPoM- R
human remelru am delivered Ina maid or which He net suitable for cremation such as premanlat or natal Omn,Me
neutral well raauimthat Me mains be moved Infra mNable w Winerb m It accepts new mmalna. The p»mng of
container"Met nsferorremoval MremaiMMIIae=Wud aforeawhnessand MIIbeireinpdvaq.withdpngwdmg .
IDEHIIFICAnM OF DECEASED
NwmseD aced. James F. Branch MCMa Status: WbOt'/ad
Len Known Ad]reea:8M Well Street, GlamorM Paint, NY 12824
Place ofoeeM:olens Falls Hospital, JOB Park Serest, Glans Falls, NY 12801
Box: ® M OF Age: 78 DOB: 0&2911942 Dale MOeaM: OBl0 om EmtmeMdwelght 7X?
Desorption W uakel/¢nlainer in wrim narrow sell be delivered.
Flberbomillalterna8ve Container, Matlbews Company
PERSON IN CONTRM OF DOMST
(/V�uy/ ((s) Mumhn'WursysT. �CNE WMe MWMM
Cn )
J 13 I iNW6 am the sNgMad agent off orm ad degnated in emit or winner inmmM pw)Aad peal W Public
C Hewlett lax Shown 4201
-0Po
INIe have no knowledge that the dewawd mecNed a mean instrument pursuant W Public Health Law Section 4201 a e
will containing directions tar Ma dieposNan M his or her matters and IMe are me awards)having Money under Public Health use
Samen 4201 and have Me right to auMonm monsoon of Me remains MMe temew . MylOur MkN Mbtp He Her dacrosed Is as
rolbws:
James F. Branch
DOS-189d-f flies 04uni Page 10 3
Authorization for Cremation and Disposition
(Iruerl nam the Wf O bw)
Number. p3 Nactlpgcn:Surviving Child
1. Ammon designated in wifte pumunt Pub& eats H i ScJan 4201(3);
2. TM¢urval aoouse:
U. The warning Wmeetic parryr,
i Any sunning child eighteen ywn rope or glee',
a. AsuMNrg parent,
S A sunning eiblly eiphleen years of age or MINI
a. Alewlully Intel goal
]. My perform)eighteen years of age or other emitted to share in the mile am whoWm tlp6ent in relatiomhipm the heaved;
8. A duly aprylntM Oducary of the estate:
g. Aclose trend or Mlt who ha¢vttukN a"Men atabmed Pursuant to Public Heats law Southern I201(7)I
10. A&let deal oMwr of a murRy,or a public adMnistratm apparel pursuml W Me 3urromme i Pmmdure A6
IN. AM Mher cerson who is acting on behalf of the dereaaed and whey has school a wrmen¢taMrcnt Wrauanl m Po lIC HUM
Law Section 4201(1).
ligged ALLT Rrf Mats andeaa7gl
XC� li hereby affirm thin Me such of Me dereal aces not wmam a Wtlery. WMry path, Power ran.national inprant,
or radiwdlN deNw and Wteny suoh malIXl9ls were remm'M Fnorm Me eixcution of thHAUMmb�don Fdm. Fellurem nmoae
Nua hei prior to Cremation my rnult In harm W tlN Cramelgy and Crxn penmrnl.
X CR In) Me aim the imo-uclipm hem been given to Sarah Ahilo
re rril ln9 the removal of aM Ferswl pgpMordMr thing stogie which any Pmmn string Mow or aM%may marnMr Media
eemaeed w;aneem preserve. Pine View Crematorium
in not re¢ppnnbb surge removal of personal ikrm"in the wmeitwor from the remains oththhe decia¢ed PanonalNma hXln Xn
none lnm or MM the mmalns MII an dxhayetl bytM cmn n process and canner ba reVNrad after emme n.
XCR(� Ifwa n.nby vmnome Pine View Crematorium
owns nw e)
to cn Wtl remains or the Minima .
(fmW roTIMAL)
And hemby aulhMte 0 a named In railer to provide for eNlvery m and cnnutlon by an aftemam
rematon. JdNmetl Informal in the opm due' Idle r,and m amend this form to provide the co ict name and
addrems of such alternate channel
FINAL 018P0 SMN
m rison N e prt to rediro Me uemnN mmaim of the M1 bon the nemaloy l¢:
Name:Singleton Sullivan Potter Funeral Home, Sarah A. Philo
Address: e07 Bay Road, Queens of NV 12804 phone: (518) 71
the ommbd remains of eememe evil bar db My an Wq :
Haa to be given to son and haH W be buried at Pins Vmw Cemetery
If br any meson the Peron romee Ywe ems rid taker pwasion My anwrat rbrovu.
Pine View Crematorium yawhpduebyepwpePnq
« won
tk mminsm Sirgkron Sullivan Potter Funea Home br gppmry
in person in by reninwee mail Jamn F. Branch
,w+wawa
COS-15BS1(i bull Prel
l Authorization for Cremation and Disposition
11�me Wiwng)
xCN)S NyageryynE Nnlltle remains an MgalmNMNbn 1YU Myadmmetlon,
Pirre View Crematorium rvydeypdre Mdw mnymN
an lmNauaOk foundr, such as by aral. rosmM
gaFad
handsME offhe ldbvMy)
Singleton Sullivan Poddr Furraml
An urn to be usM as a container for the vemud rem nne has been WrtluW fem Homa
and Is deu'ndatl as blloas
IMe understand that tithe on Ia Me Real ad Ideal ft Mare aenW hotel M addmoral had mnwner Trey W dead for MxMnt.
oa.
xC�Mum reader WrgruM. Noe uManMMNtlMm coney WrtluyMaoYrowbe povAed
Pirc View Crematorium aWN plan the vwreted emalnsin
M1�soaaw
e rlga lempoRry vnlalrwM deYmy.
Th4 ArMorbetlpn Fomrwn rtrovNeMq Sarah A. Philo was erecuted at
SierylMbn Sullivan Potter Funeral Home
Q7 Bay Road,QueeHkeansbury, NY 1250at
and is Knot by are funeral dbMw as xitrcss M had evecudW
Noe here r000 ad a correlated]Way of has ANM1wrradon Ponn.
The pemonb) IMenllfied Wbw bM1n Me parl In control 0 MMpWldon,aM10 by signed they Aumwhatlon Form,absyet
be My accuracy and cwnpNbrrw MMe Information cmrYlned In Nb ANdwlrritlon Fpm and authortre s)Ne fwadtlrq.
Stared Mb 6th yypy August ,ao''' ��12200 l
Cassius BanMar
w 858 Wall SVeat, Oiampq Point, NV 12624
disease
neewnaeerr. y....
YnTNFBd:
Sarah A. Philo
a�.Moti..w>wwe e...oam„ee+m
12689
James F. BraelM
DOS 1896f(Rev. NQ0) Ppa 3 W 3