Acker, John Thomas Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745.4476
PUNERAL HOME:
-a .S.'-- .- -�- ..._ RETURN TIME
DATE B TIME REMAINS ARRIVED AT CREMATORY:
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMVAINUH
.��CASE p _
TYPE OF CONTAINER: Vk
LGAP
PLACE OF DEATH; AT .. flOa� I I •'rF�M
ESTIMATED WEIGHT OF REMAINS a CONTAINER_____
0
PLACED IN HOLD;
PLACED IN REFRIGERATION:DATE OF OF CREMATION:
TIME STARTED: COMPLETED, RO'RT' LO 111.1
PLACED IN RETORT: 1t-IfDOA
—/I
.}—MOVED: _ I AM
O�yyl
RETORT pIN Wry1Cry REMAINS WERE CREMATED: _ Qsi I 1" I
fae,r . la�lsgt/
DETAILED REASON FOR DELAY IF REMAINS WERE
FROM
CREMATED MORE THAN 08 HOURS JD,'UI �
FROM TIME OF ACCEPTED OEl1VE0.Y;
NOTE: THE CREMATION LOG $HALL BE RETAINED d THE PERMANENT FILE OF THE CREMATORY.
DeP. New
M o(smak,
�NEWYORK Division of omsIOta OFCEsne'ERres
ta
re ne Cmn Pr
ior
"°"N "'TM Cemeteries mwe3h,,fronOwvv'
Teo ant (5181 6226
Authorization for Cremation and Disposition
This AUNmtration Form mart be completed and signed Prsorto delivery Mremtlns For Momentum
This OWMI2020 human,. 9D
Community Name:Pine Yew Crelnebrium
Address:51 Quaker Read, QOeenelwry NY 128M Pnons: (518) 7 77
CREIMTN)N IS AN IPN NSIBLE AND FINAL MOGE83.
Cremation Is carved our by plating Me remains of Me unchanged and Me wmamer holding the owners am a chancellor durroer Mere
Neyaresubp toi a lr wdaa" TMMMand Mm Ml$inclme mdconumeevery IN@xmot Band" 1,
Mich am all Met MITI M Ins enter cmingem.
Following crematecon the chemBtOry will lake reasonable Were to rerM+e all OI lee remains and ONer making horn the themadon
chamber, but some mmMal dust and residue will likely be led 0.MIM. The uemelpy wall sepmale IrcNarrtBl and Foreign marginal From
Ne wmains and the i addemel and fhregn material all be diepOMd Man moving! Who, Tlae rrtmaMd remeinBwlll de rneWniolly
Wlya ided Into small pieces and agent into a designated condemnor um. Gmrn mmimpnmllyampu"xhed MBIna
Nrgb Mgmanl as manganese an skeletal liaaw.
OPENING OF THE CONTAINER
The cemakry may Only oNn the container holding the unCrg human mneine in limited circumstances much as b canfirm Me
kknNy of Ne deceasedw Weneure Nel nit material lsezlasstl Mlcb mght Injure empbyeee ordemagetM gemTory proeM H
human remains are currents! Ina wMilnar Mlch N not suNable Fermentation such as management or nMal WMe4 the
cournatorywrill npuir thattM mains b moved Into a vulUble container before X acc rp s the mnalne. IDe Daring of a
container a the o-ansferor remm'el of nmeinawill he mnduMd CNpO a Mness and unit be tlOM In glvery, wM tlignily and 25ped.
IDENTIFICATION OF DECEASED
Name of Deceaved:John Thomas Acker Memel Mesa Married
Last Ncasn Mdw 55 Mohican Street Lake George, NY 12805
place of went:Glens Falls Hospital, 100 Palk Street, Glens Fella, NY 12801
sue: ® M OF No. a1 We: 0&2a11939 pgoO 08 M020 Eeommelwegm-. 2mile
Oempllm,of uekeVaraglmr in Mich remains all be car ale.
Longley, Carte tankers, Matt revs Company
PERSON N CONTROL OF DiS MON
(Presents)or
or Omlml or managing, make QYE or lM bMwirg)
x,J(��s�aa I amlVe are Me dessmand agent of Me demand designated in a MII or wonder Mururous evewH pursuers to Pudic
H law SeCdon A201.
qp
IMen M1aw M knowledge deaths damaged ¢vented a wriften insW meM Panamanian Publ'c Health Law skulon 4201 or a
sell mMaiMry dl crams for Me tlbpmhi0n of his or her remains area IMe am the Increases)hBNrg plenty under Public Health Law
Betlm 4201 and Mve me right N auboom crematan Of lee remains Of Me Message Wy reWom (P to Ma dxasaetl ie ae
d wn:
Jahn Thomas Acker
DOS-IMil i(Rev. WRC) Page 1013
Authorization for Cremation and Disposition
� (Mmrthwnllre list psbwJ
Narbe[ 07 Fememphon #2 Survivinu Stamulat
1. Apeapn designated in man gumming to FvI NeaM lax Sachs 4201(3).
2 Tw it"virg spWbl
U. the auMvirg domestic partner;
3. AM surrrving child elghken years of age or older;
A Aturnrving parent
S. A surviving tabtina eghteen wage&age or Olden
IL AloWully tomorrow guerdiml
T. My pearl eighteen more Of no of older entitled to chart in Use eetM and who islert clwatl In relationship to M deMBeed;
8. Aduy appoinme ticioary dine estate;
S. Acae grand or nmr$who haseenorce a engines statement puncam he Public seam tow section 42111(1):
10. A and mael officer d a county or a Gublcadmmisbda aVpdnad mrmuam to the Smmgdrs Court Pmmbm m;
fear Any deer pawn who a among On magi of tlw command and who hm mewled a wrmm movement Mohamed to PWLe Ream
law Sedan 4201p).
(ge dALL THREE d Me Mcmineg)
XAwes hereW eaim teat the body of me deal does had contain a bavrery, genes peek power wu ndaeaws implant
of MipaCW¢deWm eM that any wchmMn&e WeR Rmou2dpm to tln eaBwllm dMa Autlwrlaetion Fqm. Fallunbnmava
1Mw noon pror to mmenon my mutt In harm to tMcrmmMpy and namawry Mr nW.
�IM4 dtim MM instructions hate been given to SSarehh PPhhilo
mowing Me removal of any general prapeny or miner thing delus which any moment sianmg bebw Or My aar member dM
awaesed wlahea to proems. Pine View Crematorium
is net misconalble far the commit of MRmal items mom the wnbiMr Or hun the remains 0Me de vemil PamMFI INm all M W
comb in�er�or wfm me ermine will Indmmoyed by the commerce prosesIn elver m and cannot rdmee .egation.
'J)A mwammbyaumomae older View CremaWium
m�mmrmd
w cimuta IM nmaM d tM bared.
(ICI orrrmen)
awe haaby allMobne me named farm motor pruab for Memory M and onmman by an alteea
caemMioi.Mnmnem.aanmryi lunge apt nice t Funanl oraswI,and wamane the roe to promise the wnsn name and
FINAL DISPOSRbN
the person authorized to Tenth Me mmatb Nadi Of for beeed M1em M vwMay is:
Name:Regan Denny $taffoN Funeral Home Sorrell A Philo
Marcos, 53 Quaker Road, Oueenibury, NV 12e04 wont: (518) 792-1114
me demand mm.ina of bcamad and bedhem l dasrave:
To be rewmetl W wire, Donna
naany macs Me Mason normal ease aces net below forma en dine vammedm M
Pine View Crematorium hemmtedmpnpeea
M mmainam Regan Denrry Stairortl Furvael Home Iryatpmry
ro
in mends arty mgisared eau. Jobs Thomas Adror
DQS-i8g8{tRev.etl[g) m.e pap2d3
uthoriudon for Cremadon and Disposidon
�( f�m� �a mwanm
XL�Irwe unMnbM thap ine remains am me townwe iMin 120 game elimination.
Pine View Crematorium may depose efi"remains in
a..eo.v.N
an areme..Me manner. such as or¢os"nne.
CREMATION CONTA NEMON
(Ipmdl ME or the rollawirg)
Ragan Denny Stallard Funeral
M urn tons uxo a¢a mnuwrMtle uxrebE mmasn M1es Seen WrNwa!M1om Hums
an0 b CesvReE az fol lovm:
NW uMvs4no NM if nre um a Im ama310 ME1M1e more oemaNtl nmamA an gathered mel mrMiner in""used MdYiveng
as
QLY_An an a my M puchimang. 4We uMenlaM gain N ro um is pumm mail or oneness gwlded
Pine View Crematorium will plce has cremate remains in
mm,, +
a rqM imlpwy rnieimr M wh hen
TNs neMeroaaen Form was prevNed ay Sarah A. Phllo was ea in
Regan Denrry StaRgrcl Funeral Home
53 Quaker Road. QuseneWry, NY 12806
and idgad WMe,funeral forever n n+lress 10 its eucunon
INh M1erc meni a compWM may of Me AUMorizMon Form.
parents)no " �n n tln signing
s auoµto M cunq eM dwnplNenNs o11Mfamdn"anYndtl0s AUMmgl
Signed this Igm "yet Auqun 20
Donna Acker
usiriermi
55 Mahican Sheet lualke Get NY 12ad5
Vietnam:� � � Q Sarah A. Phllo
12a69
John Thomas Acker
w.�aw�n
pob-1ggBa(Rau.0Y30) PW3W3