Fenty, Robert A. Pine View Cemetery & Crematorium
Quaker Road
Queensburyl NY 12804
(518) 745-4477 or (518) 745.4476
FUNERAL HOME: __ B
RETURN TIME.
DATE & TIME REMAINS ARRIVED AT CREMATORY:
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT p g R (� LOD
ELIVERING REMAINS:
NAME: ._.-.—._ W. K_.FEI' _..
CASE R _-t2
TYPE OF CONTAINER: _^ _„_L♦♦ _ = � «
PLACE OF DEATH:
ESTIMATED WEIGHT OF REMAINS & CONTAINER____ /1 e I
to 16. 6_
PLACED IN HOLD: I
PLACED IN REFRIQERATION:
DATE OF CREMATION: --
-
TIMESTARTEO: __ _ TIME COMPLETED: 9. ytiph
PLACED IN RETORT: ---
RETORT 0IN WHICH REMAINS WERE CREMATED:
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN
��
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CIMMATloN LOG SHALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
�EWYORK pIVI510R Of cepemrremwwro
STATE IY • OMSIONO OFQMEIEM�6
OPPORNMITY. Cemeteries 99WesNnvbn Aaw sm
122311
Telephone IS61(IKcae
Authorization for Cremation and Disposition
This AUWw=n Form most OB completed and signed pnorto defivery of remains for answered.
Daley I I f 7O2 ) Number: 91$
chiralName: Pine View Crematory
cower New.Domesday. W lithe 518-745H77
Address: PMre:
CREMATN)N IS AN IRREVERSIBLE AND FINK PROCESS.
Cremation is model wr by placing tie remote of the demeeaa and Me rvMamerlWding Me remains into a estimation c amW WfM¢
May am subtended MIntense teat and nerve. The I t add flans will incinerator err comma everything except bane and mNl.
which are an Ma will W left asset aremmon.
Following erematm, the cremaory wit take reematme Sit to remove all offer remains and other malenal Tom me oemal
Member, but some minimal dust and resume will MAY be left behind. me cremamry Mo eeparele m6aental ara ioregn metenal eom
Me remains and the muesli d and foreign material will be Mepged of as hall by lae. me uematea remaim will be metlVnielry
pmNenned into small parmusams placed into a designated conlail or me CmmabaW emgeniallyaepulwrimdurr5in0
Single fragment is recognizable as axNNal mmue.
OPEN NO OF THE CONTAINER
The crematory may only open the corrosion holding the un-G 10 human remains In Malted crematorium.soon a5 to confirm For
idrafty of deceased or To ensure Ma no material Is Sparred whim might injure employws or damage me crematory prcyny. If
human remains arc delivered in a wnbmerwnlm is net suitable for cremation such as common sal Or rental caabl,tie
mamry will require holding remains be moved into a sunable container Will Necceph tie remains. The opening ma
mnamerormeoanslerorremoves Wmmainswinbemnduc near¢svAnmsandwillWdoempri ,mthdignityandmpx .
IDENTIFICATION OF DECEASED
rvam.of combined. Robert A. Fenry Married
Mantai same:
east Known Addren: 4 Davin Ct, Oueensbury, NY 12804
Place Of Dowle, o f
Sa. ® M OF A4e:91 Doe: 7/1 one MDeaM: 11 bo rxlnmea wtaglRlBC'a
Descridion of mixelk ner in whin remains wk be governor.
McDonald basic cremation container, no interior
PERSON IN CONTROL OF DISPOSITION
(Porsm(5)MmNM OIdspWifmn, iNNai DNEnflie Mbwup)
I anti are the designated agent ofMe deceased designated in a will or wntlen instrument rebound formed To Pudic
Npnn taw Social 4201.
N1b have sf knowledge rMefoma Ile aemr me
ns an xUsearWumempursuantm Purvis Martindy under Lew seaim 4lum airs
rdSon ghettoes for Mea formal of Me
msa Of are Mepawn(6)ssurglationunam the d Kahn Law
seaionezht am have Me rgmM auMrme esemefion of Mti ranaim otibe ee�ea. Myrou.relationship Iona aeceaaed M an
rolrow.:
Robed A. Fenry
DOS1886f(Fag di Pape 1 o43
Authorization for Cremation and Disposition
m arebr ml
INJs understand Nat iRb wrowns am W aainMa Mhb 120 ways Mvmne4on
ina uaw crnmaroy may GHpme of the remains in
an nmNevable manner, Hoch as by soalbdng. Aw�aa,Ml
CREMATION OONTAINEWURN
MediaZONE NIMMormigf
An um IO be read as a con eiiKK for Me transit Kmane NH been Wmhemd tom
and iH described as follws,
Men undatened that if the An a IM I Io naa Me entire anamelea barriers,an addi had cMWner may he used her dere ry.
-OR-
An Um Is net y&Wrnrp961 INJe understand that ano wniH Sediment aoNavnM OrONded
*Vet CremeNry
cool plaoa Me nemaba remains In
a WA tamUOlary ormainer be emirery, m..✓ownn
Particle Miller
Tim AYMOr4a ford wets recorded by "a barmad at
Brewer Funeral Home, Inc.
24Chwuh St.. I Weema, NY 12M m"seeri
aM m Sgi by the hmebal director an winners to as emween..
INYe have reserved a competed copy 0MIiS Authorization Ford.
The pemonei idxNfied blow i daba Me pmonls)in commit M dlaposi who by oieritg Nis Author meon Foam,etlnce)
M Me accumoy and compMmd of Me Information combined In MIS AU om = Form and au oHz s)Ne foregwdq,
Signed MIS dmyorAi )5uc&
David Ferry
alp i is HC—rlinvitj R j� r o a cx QCxU
were
sweet
"TNEss: (�
f'ww MYler Aie n
wsrwjrrynu (!vom
12AB5rn mramm
Robert A. Fenty
DOS MASI =15) FaYSmS
Authorization for Cremation and Disposition
(inwdt Manse )
Numbed Description:son
1. A worse designated in wnlmg minunilW Public Heald lake on Q01ra
2 The surviving spouse:
'L. The surowng domestic partner.
]. Anyaurvirind child dampen years of age or older:
Al Asurvrving parent
S. A summing abllnd eighteen years IN age or all
S. A lawfully apryinted gum ian.
]. Any pants)eighteen years IN age o'older ended N shin In Me Mtle and who idare tlosest in responded Warre dscused,
8. A ally apWhttetl fiducary of He estate:
8. Adow Mend drell whe has exerted a wiftn sletemem pursuant to Pudk Health Law Sewon 0201(0,
10. A chat Pusl officer W a muddy car a publicadminioPlan appointed pursuant to Had slmogate s Com Pmceal Ad.
lat AM dhm person who is eNng on behalf of the deceased and who has executed a argon stMemant pursuant W Public Heats
Law seaim 4201 p).
7THREF 0tM Midwest INYs hereby affirm Nat me eddy of the deceased does not complain a ban" binary part, power m0. Wall impt
or adiwaive device and that any suct meteries were removed prla to the executor MNis Aumanaatlon Fomr. Fawmmrsmow
m Ipma proutcmmabon may result In harm to dap counsel and erematon ph m soel.
was Wm that l naw gi nth instructions have been Parma liters
n un
_
regarding the removal of any pemonal properly of either thing Nvalw which am person signing below ry any family member ofme
Pine comes Cremaory
deceased wishes to Pool
is net
n responsible m ble for e oval of ilemakmed m o lnla sea th
Merof M1om iM1e remains olthe tlemaaed Personal Neaps left In fine
f f with the remains will b by m m e destroyed a cmetlon mddt and cannot bar retrie,ed after cram Won,
Pine was Cremtlory
tale hereby alMadze � �1
romernate Me remains of he baseball
FINAL 0ISP01171011
The canon aulhwaNW reeve me oemaled re samede WM1 Meaemtory w:
Braxm Furcral Home, Irc.
Name
20 Church M. Lake Wjcdl NY 12W 51�7aa
Address'. phone
The aemaea happens of deceased will lee disposed of as fdlms'.
Returned to family
If act any reason Its Fenn nmmed eGtlae does mltake gasesam of Me oemated!remain,
Pine Yew Cremakry
ir�mrm,°t H wNdzed W gtre Wsae lion IN
Me remains In &exa Fureml Home, lrc, by ddkery
in psrem or by registpW mal vwae.nwnt
Robert A. Ferry
DOS -1(Rm OflryS) ironummr
DOS-1 Pall