Washburn, Richard A. Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12884
(518) 745-4477 or (518) 745.4476
FUNERAL HOME: .)IItRItN..yy_
____'.._ RETURN TIME; _ _
DATE S TIME REMAINS ARRIVED AT CREMATORY:
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERINREMAINS
NAME: R�4I�RDp�
/ —CgSE p
TYPE OF CONTAINER; FMNR '
PLACE OF DEATH: .
ESTIMATED WEIGHT OF REMAINS S CONTAINER__
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION:
TIME STARTED; ,_ I�e ev, TIME COMPLETED: Z,SOQn
PLACED IN RETORT; --_MOVED:.
RETORT p IN WHICH REMAINS WERE CREMATED:
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: TMI CREMATION LOG SHALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY,
///---��� IX Stx¢
EWYORK Division of OMSIONN°F CEMETERIES
$TREOi On¢Cammerte Pless
°m°NRrNM Cemeteries Mew antic,Avas,
Turns....one43#6116
woo,damem
Authorization for Cremation and Disposition
MIS AmmunaaGon Form must be complete and signed Now to 4Miven'a remains far cm adon.
May,., 0811412020 Number J30
Contrary Name: Rine view crematory
whower 21 Quaker Rd., 0 eensbu NY 12804 P ere. 5(
CRFMPTNIN IS AN IRREVERSIBLE AND FINAL PROCESS.
Conduct earned out by plating the remains of are de and IM¢miner holing the remains ale a tie nchamber where
Iheyeresubp Wb,hens MalaMflame. The hart and ARTS will Incinerate and consume"Wrigung RPPt tam aM matt,
which are all that will be left after cmmabon.
Fallowing cremabon. Me aremaan wall lake Mandate arcom ro remove all of the remains and Mher materiel from the uemalbn
Member, bid some normal dust and residue vall lildi be kh behind The umnsary air wparet lraieentl and but m tern Me
the remand and the irulantl and ledge matrul Mu W eisposee of as requires by law. The cmnw W me ns WO day maManiulW
prommed into small pkwa and plawd 'into a designated currency a um. Cmmstdn in Abdu ly are WNsr'¢W until no
single fhapmant 4 mwgniuble by$xomti bathe.
OPENING OF HE COfggNER
The rotor My Only open the Computer holing Me urveremated human remains I n Ilmikd Cl hour Mmm .soon is owning Me
kanpy ofthe Measured a In ensure that no material is enclosed which might injure employees of damage Me commit pmpeM. N
human remelna are delivered In a container which b not adhandle far cmmabmn auch as amma day l or NMal this W.Me
mrtory will require Mat Me t in$be moved Into a suitable consumer b M It accept the remairm. Taleopenirgofe
container or Me transfer or removal of remains will be orml before a whneea and will be done In pevai w dgnooneffl H
°ENT F CAT ON OF°ECEABED
Name a Deanad. RiehaM A. Washburn Medal statue: Manled
teat Known Surge, 2514 State Route 28. Nash Creek, NY 12853
Plea of Deem: Deceased's Reaitlence, 2514 State ROule 28. North Creek, NY 12853
sex., ® M DFAge: 82 DOe. 03/0511013 Drtedw 0811cul Esembedweigm 180
ceacnpdon 0 agandonewher In Mich remelt mil be ddivetd.
Florence Casket-Deluxe cremation container
PERSON CONTROL.OF DISPOSIl
(Forecasts)in cowfM o(&r ,, MIM1SI ONE of the slowing)
I emM1Ve are He designated agent of Me dereaee designated In a will or winen IneWment mewM punuanla Public
Hearn tow Beeson 4201.
-oR
5,. Inge have no know e th
at Me tlxac eee executed a women Instrument SulMason to Public HmuF Law section 4201 Ora
p coNainirg directions for the Dropout n of his or fall where add I1we are the p rmnpl having Gorily under Public Health Lew
Sttgon 4201 and hove Me right t0 aumories crenudon of the remains of the de¢ . MyMm MNlamhlp a Me d✓.used is as
m '
Richard A. Washburn
D06-1 erg&(deer.0o201 Page t of
Authorization for Cremation and Disposition
nnseRfiom the nP prow)
Numbar: 2 Dori Burirvna Spouse
1. A mmn designated n amonO pursuant b Pudic Health taw,5ction 421;
2. no surrinnp spouse
28. The sum'wng domestic caner:
3. MySre ring child apdren years or age or aam
M a. Asuring parent;
s. A strong sibling eghtxn years of age or omen
S. A leMully appamm gumdan:
f. illy persons)eighteen years of age or older ancient w4tars In to wool and who ware dorm in mlat0.nNie to Ue deuaaed:
8. A doy stared fidunary of me elate:
9. A cpw Mend or relative who has executed a argon statement pursuant b Public death Law Sheri 401(]);
10. Ach'mrnscal ffO N at 8 county or a public ad miniavna appointed pursuant to the somgate a CwnR verdure Act
1011. My acres Mul who is acing on behalf a the derami and who has executed a wrimn statement pursuant to Public Heats
Law Section 4201(7).
bblid ALL THREE of Me TM,bwlnpf
gave hareEy affim Net the bMy,of Me decreased does net contain a Later, baaery peck, power wll, radioactive Implant.
or radiaid"device and that any surf malenetwere removed show note execution antis AWh &x nFort AIWnmremove
Mass gems pMrtocremabon may result In harm b me cannot and Mona chy Personnel.
SW I/we affirm mountaineers have been given b David Alexander
s....rowam.y
regarding Me removal Many Personal pmpeny or mher Ming of value which any person opining baba Or am family rremler of Me
deceased wishes W preserve. Pine View Crematory
move"nm*a
is me responsible far Me removal of personal items from the annotator from Oe remains of the dmwwwwd. PemMetN slaaln Me
maestri will Me nmalna will the de6fveyed by the mmanm prime and cannot be rNtleved a c Con.
SLJ McMraayarnhoNe Pine View Ciamp Y
"an vavW
W cmmam the rxrelm MIM Mcassed.
11n(ffif OPTIONAL)
tom hereby,instance the named funeral thereof to provide for delivery to and cremation by an alternate
nmaWry, Mdeemed necessary In the opinion of to funeral dimMon and to amend this form to provitla the comet name and
adders of such alhmab crematory.
FIMLD19PWRIOX
The Person au omw to mwive Me vemahN RmeinsM MCdtteamE Met her pemrmy is
Home Alexander-Baker Funeral Home, David Alexander
Address, 3W9 Main Street Warrensburg NY 12885 Phone (518) 8232085
The uemMed mmaim atdece Wwill the disposed of as lalows:
Retum to family
If foram goal Me Person named above doer nah Wks pwae dmin acts vented mmairu,
Pipe View Crematory Is out v b give Possession of
vi've",even
the remains Alexander-Baker Fungal Hone by delivery
aww"aw a+m
in parson or by regwemd mad. Richard A. Washburn
DOS-18W(Rev. NRO) m� Pgy2of3
Authorization for Cremation and Disposition
f `Ma Mee� 'Mai
5IN/e understand time 1the remove ere not claimed main 120 Wye of cremallan,
Pine View Crematory may dtepee of Me renew in
an inelnevede manner,such as by suNflna. nw�ue+mn
CREI TION COMANERNRN
SASS(ONE ortav ldbx1rgl
� W1 Aexander-Baker humeri
urn m to uses as a �nfainer rorthe Demme remain ban coon purchased franc
and Is balanced as MIME, Chessi Pi ldne"Me urn
We unbemtail Mae it 1M um is too small b had the entire mmdmd1 renew,an Additional hi container may AS used for mairery.
0.q
An um 19 not yet puMexd. Mile understand that it no um is purchased or interested promised
Pine Vim Crematory all place the cleared remains In
ww V✓ j
a rigid compo wary container for delNery,
This Authorization Form AM pronced by David! Alexander was e.ewtedn
Alexarttler-Baker Funeral Home
3W9 Main Street, Warrensburg, NY 12685
and Is signed dy Me Nndnl director as wines&to its exeouelon n
IM1Ne have remlved a completed wpy of Nis AUNorma kar Form
The peraonlsudmtlned below Islam the Moraines) in obese of dispeoition.who by signing this AUNorlaalhom Fame.Mail
to Me accuracy ace eomp on«e of informalconlained In Mie AUMotlaallon Form and adlemaata)Nw Remaining.
SignedM 14the.r of August
Sheila A. Washburn , 20 �.`
ipp IG)-C,AI'/ u',U,t1
m w n•
2514 State RONe 28, earth Creek, NV 12853
n...e..as.m. ss....
wITNEba: /
David Alexander
1003C on..ax.,w Asia
RIchard!A. shbum
Di lads!(Rabi 0WO) area 3 of