O'Rurke, Sharon Irene Pine View Cemetery g Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745.4476
FUNERAL HOME:
�Bn -- RETURN TIME:
DATE A TIME REMAINS ARRIVED AT CREMATORY;
_
NAME OF FUNERAL DIRECTOR OR REGRISTEREO RESIDENT DELIVERING
ELIVFgINO RIMglN3:
NAME: _- rjk
o'Rugyg___-.-__ _
CABEA _ I
TYPE OF CONTAINER: �_ Lylly
PLACE OF DEATH: k� I I�
ESTIMATED WEIGHT OF REMAINS 8 CONTAINER—
PLACED IN HOLD: �pffi A� 300
PLACED IN REFRIGERATION: 1111
DATE OF CREMATION:
Y N YO
TIME STARTED:
TIME COMPLETED
PLACED IN RETORT:
RETORT p IN WHICH REMAINS WERE CREMATED: _ � p�
oz
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE R RE THAN 8 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SHALL BE RETAINED IN THE PERMANENT pLIEo TF HE CREMATORY.
Authorization for Cremation and Disposition i fs.ski If Son
on.mmmn, ewn n�`Fone:�n.a
"s, 12231
n)<74ziu
This Aulhonzadon Form must be completed ar signedprior te delivery of remains for cremation.
Dan: lIblla Number Ila
Crematory Name: Pine Yew Cm Wu
A mas_ Quaker Road, Cincinnati New Valk 128W Phone: 5161745-,477
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Crematlon is carried out by placing the remains of the deceased and the mnulner holding the remains into a
mation Member where they are subjected to intense heat and flame.The heft and flame will Inane and wnwme
eveMhing except Isere and metal,which are all that will be left after crn on.
Following Cremation,the crematory will take reasonable el to remove anot the remains and other material from the
cremation chamber, but minimal dust and residue will likely be haft behind The crematory will separate lnddental and
Foreign material from the remains and the incidental and foreign material will be disposed of as required by law.The
cremated remains will be mechanically bulvenced into small pieces and placed into a designated container or um.Gemeled
remains generally are wlverimd urge no single fragment Is recogxaable as 4 IMI time.
OPENING OF CONTAINER
The crematory may only open the container holding the umcremated human remains in limited circumstances, such as to
confirm the identify of the deceased or to ensure that no material is enclosed which might injure employees or damage
crennattly property. if human rebates am delivered in a small which is set suitable far Cremation such as a aremonial or
rental ms ,the cmnatmv wall require Mat the remains be moved into a All mnulner before it amepts the remains. The
opening of a container or the transfer or mmowl of remains will be conducted before a witness and will be done In privacy,
with dignity and respect.
IDENTIFICATION OF DECEASED
Named Degeaeed: �h?i[]n T.CpYs¢.. Onr A-Ilz. MadGlsMam: rykarciogi
Lent wrOwm nddreaa:/4 ```` `` 11 3o G a o
PWce d Daeth: GI,,y,Q �P S H�'Y�l
Sex: DM )4F Age: DOB:DOB: U4ll4 / 14Sf1 SOD" :Mil xo Ewima Vd aM: 3 of S
Description of casket/container in which remaiM will be delivered:
Corrugated Cardboard Box with Plywood Starmark Model a 38808
PERSON IN CONTROL OF DISPOSITION
(Perwnls) In control of disposition, initial ONE of the following)
I ate We are the designated agent of the deceased designated in a will or written instrument exeuuted pursuant to Public
Health law section 4201.
-OR-
I/We have no knowledge that the deceased executed awritten instrument pursuant w Public Health law Ali 4201 or
awl? cdntainire direction for the disposition of his or her remains and lCominued nert page)
6ww IMp S1 C2, Rza ke. wa.awa
ww�
1
I aM"am the personls) having Fill under Public Health Law section 0201 and have the right to auNorize cremation
of the remains of the Maxwele Marcel relationship to the deceased is as tminws:
(IRMOLesm dWwt ebw) `1 (1 1
Number;�IXscriplion tl 'S�vs1�
A person designated In aTMng pursuant In Pude Heats Lane section 4201 (3),
OThe SllnMrlg spouse;
b.The surviving decrease formal
J. Any survhdrg mild eighteen years of age or older',
C A surviving parent',
S. A surviving sibling eighteen years of age or older',
fi. A lawfully appointed guardian
2. Any personas) eighteen was of age or older enWW M share in the estate and who causes closest in
felatMnshlp to Me deCSaaed;
8. A duly appointed fiduciary of the estate,
S. Ado MwdormlaO"e oFasexewk all ns WmerrtpumuarR Public HeaMh §4201(7);
10. AMWfiscalofficerofacount'orapublkadministmWrapp intedpursuanttothe SufrogaWsCourt
Procedure Act;
1Oa.My other person who is ailing on behatt of the deceased and who has executed a winter atatemeM Wrsuanr
to Public Heats Lax§4201(7).
llnrlloll LL TXflEEA'Me,mYox gf
I/We hereby affirm that the body of the deceased does net contain a battery battery,pack, power cell, radioactive
implant, or radioactive device and that any such materials were removed prior to the execution of this Arboreal Form.
Failure to remove these kerm prior to oematbn may rema a In harem the cremamry and aemamry personnel.
I/We hereby affirm that instructions haw been given to emwaareamvvxr Cassado crtv>l<1W regardingthe
ova of any personal property or other thing of value which any person signing below or any family member of the deceased
wishes to Fresery arsemnyxnx) Pine been,Cremamry is notresponsible for removal of personal
items from the container or from the remains of the deceased. Perswral Hems leis In the container or with Me mergers will be
desemyed by the cmmgt n emcees and mnnot be rehleved aRer rmematbn.
/We hereby somehow,rc vrei nmmp Pine View Cremamry to common the remains of
tMdecemed.
FINAL OISPOSRION
The person authorized W recewe Me Cremated remains ofMe deceased form Me Crematmy 'e;
Name'. Baker Funeral Home Personnel
Address'. 11 Lafavede Street Queensburv, New yolk 1280a Phone (518)nt-IXIO
The cremated remains of dismissed will W happened of as follows:
Return to family to be decide al
If Mr any reason Me pennon named above chose not take possession of Me cremated remains,
woma ,nwwl Pine View Cremator iseuthor¢ed m give possession of Me remains to
Baker Funeral Home by harivery in person or by renewed mail.
SR,a. o'K0.1lbs.
Doswell i Lwr Turns isswomnue red la
. hvievl mefannwmgl
IN1N understand that if the Rmains are not Claimed within tID days of cremation,
lw e.al Fire View Comments maydiwoseafineremains in an irmbtevable manner.
such as by mortairms
CREMATION CONTAINERA/RN
IniriolOrvFa/thejollowmg)
---- M um fa b s used as a container for he cremated remains has been purchased from Baker
Funeral Hanks and is described as allows:
INJe understand Nat N the um a too small 0 M1dtl the same cremated remains, an additional ngk container trey be used
far celsi
-OF-
AKAn um has not yet been purchased. bWe understand Nat K no um is purchased or otherwise provided (,M w vy
.col Pine Yew Crematory will place the cremated remains 'In a rgid Temporary
container far delivery.
This Authorization Form was provided by lP�amwnmmq Ozsa RaffeMp141W
was executed at pumwaamemmel Baker Fune2 Home
lrwiwwrwma wi..N 1l tafavede Street Oueensbun New York f2306 aM is signed by Me hundred director
as summer b Its executron.
Area have received a completed copy Of his fidtMO Muss Form.
The parsons)manNTreC below mans the persons) m conhd of automation, who by mining fMS AUMwizati0n
Foml, adesl(s) 0 the aromi and completeness of Me mulazzaflon wntamedf in this Augrodzalms Form and
aut0ozize(s) the foegaii
Slimed Mts \a day of 20 1
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aan ro up cow
WITNESS:
f:essu RaRarty 1` ,
w.earvmo-rm�emmrawme wmdnnvsweo^e
Funeral home Red. 01130
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