Newcomb, Barbara Ann Pine View Cemetery $ Crematorium
Quaker Road
Queensbury- NY 12804
(518) 745-4477 or (518) 745.4476
FUNERAL No.E: RR,���.�
•��[- - -._ ._..__.._ RETURN TIME;
DATE 6 TIME REMAINS ARRIVED AT CREMATORY: ,__. 1I131b j
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING
NAME: ._____._ 6Aeenea __UEII(GHB __
I�CASER _
TYPE OF CONTAINER:
PLACE OF DEATH: 35 (,,_ y/ _ �f��—�r�
ESTIMATED WEIGHT OF REMAINS 8 CONTAINER______
PLACED IN "OLD:
PLACED IN REFRIGERATION: � _ _ _ Z(M\ _
DATE OF CREMATION- Viol lb
STARTED: Viol
TIME COMPLETED; __ II'M N
PLACED IN 7:7ftp1A
RETORT IT IN WHICH REMAINS WERE CREMATED: _ _ 1-- -g 5011. 11
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN AS HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SHALL BE RETAINED IN THE PERMANENT FL� EG Tr HE CREMATOR
AuthorizationJor Cremation and Disposition m5orwamaw,rwn
w,uiU nnhr
pne Ummem N¢ were
NY Mod
wwd Mil nvtaRal
ISIDI<R6S16
This AUWmlzatlon Po m must be completed and signed Prior As delivery of ramalpa Mr Cm atbn.
Date: SIoIA Number 27,
Crematory Name: Pine View Crematory,
Addmsa: Quaker Road, Queensbury, New York 1MD4 Phone'. 5181741
CREMATION 15 AN IRREVERSIBLE AND FINAL PROCESS.
Cremation is carried out by placing the remains of the deceased and the container holding the remains into
cremation chamberwhereMey are subjected to Intense heatand flame.The heat and flame will hulnerice and consume
everything except bane and mural,which are all that will be left after cremation.
Following cremation, the crematory will take reasonable efforts to n of the remains and other material from the
cremation chamber, but some minimal dust and residue will likely be IM behind.The crematory will separate Incidental and
foreign maten a from the remains and the Incidental and foreign material will be disposed of as required by law. The
macal remains will be mechanically pulverized into small piec and placed Into a designated container or urn. CrcmNetl
rc Mns generally are poisoned until no angle fragment IN rtrogriuWe as skeletal On".
OPENING OF CONTAINER
The crematory may only open the container holding the on cremated human remains in limited circurnmanres, such as to
confirm the idermy of the deceased or to ensure that no material is enclosed which might Injure employees or damage
awry property. If human remains are delivered Ina mnmererwhlch Is not suitable brcrcmatlan such as a¢rcmanW or
bnbl casket,the rmba ssy will require the the remains be moved Into a sukable container factors A axepN the remains.The
opening ul a cor:ro ver or the transfer or removal of remains will be cond Land before a witness and will be done in privacy,
with dignity and respect.
IDENTIFICATION OF DECEASED
Name ` l q
Name of Deceased. \Y1IY�C Q N •r, u++u1J Mantal Status: macr b d
Last Known Adddr1reascs: A a 1 a
Place of Death:�
Sex: OM 4F Age: �i1f1$6 Date of Death:() 11 &LaoEefimabdvv"m, LM165
Description of casket/container in which remains wilt be delivered:
dCardboard Box with Plywood Starmark ModelN3
PERSON IN CONTROL OF DISPOSITION
(Personis) u. comm l ofdisposition, Initial ONE of the following)
I am!Wa are Cie designated agent of the deceased designated In a will or written instrument executed pursuant to Public
health Law extinct 42D3.
-0R-
-,I/We have no knowledge that the deceased executed a written instrument Pursuant to Public Health Law section 4201 or
containing directions for the disposition of his or her remains and (Continued next page)'itiva g
r rq CDiv.,4b
[meow I Isee ot,:ol mmeptnxe marans
l avi we amthe peron(s) having prgrity untie-Public Health lawsMion 4201 and have the right to authorize Cremalon
of the remains of the deceased My/Our relatlonshlp to the demanded Is as follows:
pmert)imm the to below) `\
Numbei Deserlption: l"ylY]
A pelsen designated in writing pursuant W Public Hpalth taw section 4201 (3):
ITThe surviving spouse.
The surviving tlomrture paoner.
3. Any surviving child eighteen years of age or older:
4. Asurviving parent
6. A surviving sibling eighteen years of age or older;
6. A lawfully appointed puncher;
y. Any pera0n(s) eighteen years of age Or older endHed to share in the estate and who ialare closest in
relatiensM1ip to the deceased,,
S. A duly appointed fiduciary ofthesstlte,
S. A ease friend or relative who has executed a written statement pursuant to Public Health Law §4201(T);
10. A chief fiscal officer of a county, or a public administrator appointed pursuant he the Straighte's Court
Procedure Act:
1 Oa. Any other person who is holing on behalf of the deceased and who has executed a written statement pursuant
t0 Pr:blc Health Law§4201(1).
di dhLAu THhcE O)the face w,ngl
q;,e hereby affirm that the body of the deceased does not contain a battery, battery pack, power cell, radioactive
Imp m, a, ramoacave device and that any so& materials were removed prior to the execution of this Authorization Form.
False to remove these Items prior to a matron mry result in halm W tMnenrabry and oemabry myymh neL
rC v /WpM1pr¢by affirm that M1]Vl been ghren to M�emi eamwmmel idde Rolkrtv Mf41W regirdinglhe
al of any personal pr0party or other th rig of value which any person signing below or any family member of the deceased
wlshesWpreserve. Iva.wmm.�y Pine Vew Crematory, is not responsible for removal of personal
items from trc container or from the remains of the deceased. Personal Items left in the coni or wNM1 the remains will be
destroyed by the cremation property and cannot be retrieved after cremadgl.
tM1tl [ I/We hereby authorize(pmmerymmel P'ne Vl¢W trema[ory to cremate tlMramaMs of
t9ased.
FINAL DISPOSITION
The person aatImm ed an receive the centered remains of the deceased from the crematory is:
Name'
Access 11 afrawiffint Sleet. Quatrefoil 04 Phone: 518) 761A303
The cremated remains of deceased will be disposed W as follews'.
Return to family W be decided
If far any reason the 0eson named above does nothing possession of the cremated remains,
lamwie-mairnl P' U is auulormed re give possession of the remains M
duevicen, l by delivery 'in Person or by registered mail.
P y q
.abd�ly�rua/ejorr yl
p IMk understand that if the remains are not claimed within 120 days of cromatlon,
(o�.b tire/ P tie V ew Crematory may dispou 0the remain In an Irretrievable manner,
such as by scattering.
CREMATION CONTAINERNRN
tonpolFof rhrifiv wing)
_Pre urn to be used as a container for Me cremated remains has been purchased from Baker
Funeral Home and is described as follows:
IAAA understand that ifthe urn is the small to hold Me entire awarded remains, an additional right container may be used
mrdelmery.
-OR"/
An urn has not yet been pumbas id. IN\@ understand Nat if no urn is purthased or otherwise provided barrel
Pine Yew Crematory will place the cremated remains in a ngid temporary
conamer for deanery.
This Authorization Form was provided by tosswd�,..s,�vosy Casna efforts,
was executed at Osreram.ovirsm:l Baker Funeral He
Mrea'ai ,i varr i 11 Lafavetle Speak Oueensbury New Yak 1280J anon Ia signed by Me fune2l director
as witness to its execution.
lMe have receired a completed ci of This Authorization Four.
The persons) idonfihed below ierare Me person(s) in canton ofdispovtiory who by sgniry this AUMwlzafion
Form, attests) to the somebody and mmplataness o the in iarmatlon performed in Mis AUModza6an Form and
a othoomborr the hregoimJ.
Signed tAtF ,�tM day of�� 20
1aa _4R
Awks. —T
— taw"
Awl
VOTNESS
Cass; Rallem,
Faesownwryw wa"UrInvmz lwvx aarsu5rymun
Funeral Home Red #01130
wmnvu_...ruri
also lour as