Palombo, Andrew Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745.4476
FUNERAL HOME:
.fiS;P. " ._ RETURN TIME:
DATE flTIME RE MAINS ARRIVED AT CREMATORY; Q)Iyli n
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERINO REMAINS;
�.__.___ pL�hs�ss�n4 pWnJ�STE7fT Na__
NAME: __. 1NnRcW _-IAt OM1�j(� __
pp -- _CASE r _�L
TYPE OF CONTAINER: __
PLACE OF DEATH:
_._ --.FBI✓�_)_..__.QuEwI.fBJ� �ygpy
ESTIMATED WEIGHT OF REMAINS a CONTAINER_____ 2 '
PLACED IN HOLD;
PLACED IN REFRIGERATION: __
DATE OF CREMATION: -�-
y�
TIME STARTED: � WP: 1 C TIME COMPLETED:
PLACED IN RETORT:
_MOVED: J lb'Pn
RETORT pIN WHICH REMAINS WERE
CREMATEP. �p �(--
DETAILED REASON FOR DELAY IF REMAINS WERE CREMgTEO MORE THAN 45 HOURS
FROM TIME OF ACCEPTED DELIVERY;
NOTE: THE CREMATION LOG SHALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY,v
w Sate
0.yNn•n+M SM1b
NEWYORN Division of DMSID0"comCEMMRIM
From
)` SATEOF metre<lommerce Fexe
PPORTIMDY. Cemeteries ee. �n.menw
231Dw1
reserve:,salma522S
Authorization for Cremation and Disposition
This ANFwlauon Form must be committed and signed Prior to delNaw or remains far CraMtlOr.
Gam: OWIV2020 Number: yZl
cremahay Nam Pine View CMMOW11D1r1
ktdresm.51 Quaker Road Due trnbury. NY 12804 Prow. (518) 74 77
OREIM1 IS AN IRREVERSIBLE AND FINIAL.PROCESS.
Cramatim 'w c9mied bin by plating 1M remains of 1M dsmawa and the consul facing Me remiins iMp a oam9lkin tnambr W M
mar are..gads.m iMnx nm+ana Mme. m.nmt.m wMenn mdnereta .aa mmam.MryNlrq aawd bdlwarre mMl.
wnkn •n•IIMel Fdl me to IMaMr crMwowirp counselcounselueMtoryunit lake
reasonable eflon¢toreMw all d IM remains and o i mammal Min MecT al
Membtt� Eul some mnimelau51aM re¢laue will IIkNyMleN ro111M. TM vameldy MII se omirc mlaMmilMmebnham
pulverized
smeipecanmld pcedanmadeNMobe aiapoaed of prpuindb renothaaamsda rem.inavnnbe 111 nloauy
single
into¢M11 puma and paced s into a designated conleirwrn am. cramamtl nMlm Marshallese wlver4ad un41 no
.triple Irpmxa N r•coanlyM N ahaNml tlNw.
OPENING OF THE CONTAINER
him co mamry may only noun the Container holding the un<nmMd human remains In limited tlwmemnces,soon as to common the
least of me deceased or to ensure that no marcml 'as enclosed va im might Injure emgoyeea or domes¢the mmemry pmwmp N
human reMlm are delivered In a aonta inner which Is nW suitable for cremMon such a• mrbroold Or mnml cnNet.M
comatory will memorm that the remains be moved into a suradow container boom ftmompm me remains. Tire opening m e
ntainer or me transfer or remomai Of raMim tan be conducted before a war1M and will lw domain primary,win dienry and maned.
DENT F cATIDN OF DECEASED
Name of oawamd. Andrew Palombo Nantd smtm: Marr'led
tan known kmruN 47 bends DrNa. Dueensbury, NY 12804
Pmw of rabsch 47 Zones Drive, Dueansbury, NY 12804
Sae ON Of Age: 50 We MOWN() pants paam: 08/1112020 immediate weq .teat
peeuiptionMuakel/anmFer in/RniM mmd1nal w1llMalMraf. /} � � 4 ,a
C 9
PERSON IN CONTROL OF MSMMM
fPeraulls)m Cmbnr a dupmahm.�avE a are nxbw+rel
I wluwe ere me desgne d seem of Me damama designated In a Nan or wmmnInstrument emoamd purmwd to Public
4gm.
IAYa ho no xnowledae test the demeaad erocded a whaten instrument puremal Public Helm Law Sweden 4201 Ora
f� 01
y di ii Iwme dmpssMn Of his or rim mMins and IMa are me Mn (s)naming priority urebr Public HMM Law
name the rgm to.wMxl2e activation alms remain.oflife deaeud. Ryroar ml.tlomMPtoara dacarMl•m
Andrew Palombo
DOS 1e9Mf(Rev. GUN) Page t d3
Authorinflon for Cremation and Disposition
pnwn down papa haft bekw)
Number. 2 oewiptim'. Spouse
1. Aperean Eeeignl In winning apparent to Pudk IMMM1 Wx bechon 0201(3)'.
3. The wMmp wooden,
L. The WMuint hurnal writer
3. My surnot child eighteen years of age or doer,
♦ Asunivag parent
5. A writ 4bling signal years of sae or older
6. Alawfully ap«inri guerdgn
]. My pMorri eighteen years of No or order nodded to sperm the estate and who were cbsest In relationship to tM sewated,
6. A duly appointed fiduciary M Pe estate',
S. A lase trend or relable who has exewbd a written statement Pursuant to Public HetlM Law Secton 4201
10. Achof fgCel count of a worry or a public admimabxor eppoiMed Pursuant to the Sanctions a Coup Procedure Ado
toe. My offer person who is ai an LEMr of Me deceamd and who has executed a wreath national pursuant to Punic Pat
�L\M'eecrbn 4201
}NFEE o/Ure lMbwrryJ
e hereby affirm Nat tM body dPe deceued does not contain a battery, battery peck, poetical radlwdiw imply L
AdveOsuiM ate that any such malerels were removed piarb meexeMgn of pis ApgONaaxpll Form. Fa6uR to remoremoverNysseoft dorr CMme6anmymuxmharmtodwcmne Mdem in by MnonMf.
/ 0 affirm Nn MtrvabM have lreen Queen m CaidVyVon,wwwnteda in
rpekN door Nnry personal PePaM or capper thing disease wtrlr any Penton legi MlM or any lamely mrrider of five
intention
prmrve. Pine Yew Crematorium
Mi miElwaw
a mr N¢removal of peMonaI items kom rya wnaino hom Ms remiss WMe tlemaeW. PMOMIMms Ire IntlN
Ma ad's No Mmalnowlf be was by thecremeUon process
CannMbMNMaed errcremMM.
L MMy mmbMe Pine and
Chemalorlum
r` '"ter warn
mcM W mmmsawdmaeeed.
(m ' navvy
Ire hereby aoNurrt.Na named mMMt dlrmmr m provldaror ddhaM m and rnmtbn by an formed,
awn. I1 it mad in In Na opinion Mre mnaMl ofMcmr,and m emnd how
farmmPmsfatne correct
name ere
.derma M such enamor eremtay.
I'll DISPpsrtlox
Live person auNwieed m M«'me fin awned rapers OF 1M demasM lawn five vemst ia'
Name:Singleton Sullivan Potter Funeral Home, Cessi ly VonSlattina
AMr9ae: 487 Bay Road, Qusensbury, NY 128N PMm: (618) 79&d459
M aemW remYMa M«aMdwll bethermal Wits formew
Burial at St. Marys Cemetery
If mryry reason the peson named above dare Mware pommel Mfir metro rmaiM.
Pine Yew Crematorium is paramount to gone Present of
annual,saw)
ur nmvsm Singleton Sullivan Potter Funeral Home bycammy
In parent an ly registered con. Mdfaw Pelombo
WSi8B6fIF«.oY2a) Pa6e 203
Authorization for Cremation and DiapmItion
�uMeraYnd Mel HtlX nanneemare
ewCenatort n 110NyaaloemNon,
\ / Pine View Crematorium mry Yepweq Me remeMs in
1nl�Krede manner.such as Meumnna. w�.nc.ra
X RX
( She
fdMwn01
Singleon Sulliren Porter
umb MuwE eWnbinNkrtlX abl pmeiM Me[NnpYd1e66E M1Omc .... u
one is de Mdea bdawv C�OIRm �� C(a t� IC.Y
uMeMeMlnal HtlX um Ydn�Me Min aernebd mmeina en a19rvW e9ia wMemer my M ueaE M4Xivery.
OR
Anumbrbt}wlpuMUW. HWs umarWMtlW HrownY WNwdgetlwwYepmmded
Pine View Crematgbm will place the cremated Rmabs in
a new YmltMeywnYMgrord.Nwey, s.edo.wwn
TnbaaMwbadon Pam wee FroaYadW Cassidy VonStetlina was executor at
Singleton Sullivan Roger Funerel Home
Q7 Bay Road, QueereEury, NY 12W4
and IS Kned WMe small diracnraswdneasbits eaeaMbn�
li haw,mnehed a camWeMd owy Of Me Au1M1Mudon Farm.
Thep oryal Nand blow blare tlb pni In control or dbpuMon,also W signing Nb AU adzNon Fmm,aX Us
MOMS,
and CMrpbbnaN oI tlw Momretlon conlelnad In tlYaAWrwYetlon Form aM eNhwtab)Ne bnpWne.
SlBnsd Mb 12[h byq August
Reber,a Pabmbo
47 2ers a Drive, Queen sbury, NY 12W4-
r..sowex.� vane..
1Xr1r1F98:
C Shiidy VonStetena r �-
.aamoarw... waW 13709
Andrew Palombo
DOS-tee&t(Rev. NOO) Pa0e3o13