Wall, Amelia Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME:
------ ----- , RETURN TIME:
DATE R TIME REMAINS ARRIVED AT CREMATORY:
NAME OF FUNERAL DIRECTOR OR gEGRI3TERE0 RESIDENT DELIVERING REMAINS;
NAME:
TYPE OF CONTAINER: �ryTkA'IfmJ �I
PLACE OF DEATH; C�)lalJ.-mr�:4j ys_
- --
ESTIMATED WEIGHT OF REMAINS 8 CONTAINER_
PLACED IN HOLD:PLACED IN REFRIGERATION:
DATE OF CREMATION: _ Q�plfi _
TIME STARTED: _ ]:7y�y�
COMPLETED: H:IQ'(rl
PLACEDINRETORT: _ 7.304 L:—_MOVED: �_ gban
RETORT If IN WHICH REMAINS WERE CCREMATED:
—_fPuvL 4ArII
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 40 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE:THE CREMATION LOG SHALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORV.
Yk,state
Department Of state
Mexrroaic Division of °'V151DN0a earke IES
STRTEOi 99warel pmnwmue
pPPpRi°"'Ty- Cemeteries No.m.NY lzzn"Or
T.aa.a.. nlr,t94aaat
Authorization for Cremation and Disposition
//��
TWA AUMonaanon Form must be complat and signed prior W delivery a nornalm Or cnmeflon.
Dole. A u,lar 1 `{ 1 Z.6Z0 Number
Cmn ory Name. Pine Vim Cembefodum
seeress. Quaker Road Quaternary NY 12804 Phone: (518)745<477
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cromeation is they ale sublcteddtto sense war and flamel�The May and flamend the conceser will Inelnembly and consuhe megeothermalains into a cremet 0ewand were
out fly the raeea bohamber were
which am all beat will be left After cremation.
Folime g cema4on, lhecremetoryw111 take masoneble¢flans to nnmB sit arms remains and other material M1pm the vameliM
chamber bN some minimal dust and maidue Yell likely be kfl behind The cmmetorywlll separate accepted end Mdgn meteMlkOm
the remains and the InGtlenlal and foreign material will be disposed Of At WVimd by law.The cremated remains All be MSd Wlmuy
puNevd into Mal[ Mood,and placed Into a designated contour or AN CnmaM rearm no geanlry am pu lvedxM until no
single fragment Is recognkable as keletal"Due
OPENING OF THE CONTAINER
me crememrymay-may the container holding be uocrarmed human bull Mi circumstanced such as to wnflrm to
montiy,of Me de ed Or to ensure that nO materiel is moderated which m9minjure employees or damage the comment propeMfl
human made he ere delivered in v robot nor which Is not vultlble bar cramvtla such ae min anal Or natural casket@a
matory w1N repulre Mat Me remains be moved into a su efli a container baton it accepts Me remains.The openbp of a
consumer or Me transKror Rmwel of remains sill be conducted before a ormess and fall be dome In tribal MM dignity and reaped.
IDENTIFICATION OF DECEMBER
Namecf Dewaeed'. Amara Wall Mentalsa 6
Larl Nnouniaddre".I,]Q� ' vain �E Qwr ;iit
Pkmoroel .A1bo-ry iJN G
Sp:Q M [] F Age'. 0 0e, 4 1$ Dvk of Death: GET1090 Edorsed Weight ' S
Description Of awl kh mmamm All be delWarrd.
eFw tw (uKflw Et
PERSON IN CONTROL OF DISPOSITION
1Por tS)ih Ir_deIONEo/Me MHDMW;
emlWe are Me designated agent arms 0e esed deNgneted in a mil cruntion InsWmeM mlewted pursuant to Pi
Hfjaomigh Lear Reagan4]Ot.
' i IR/e men no knowledge melme centered minuted Noat1ion Instrument Presently Public Hoeft taw Section 4E01 ma
*111 err ining dlmgansfor the dkposilian of his or her remains and IMre are the peuone) hevlrp pncnry under Public Has" Lane
Section 4201 and Nve the Will to aumorhe cremation of Me remains M Me dewaed.Sri rekilonsNp W Me dae lea
ronowe.
Amapa well
Mvreorwvnp)
D0S libi(Rev. O81 Pagel AS
'-Adhoriration for Cremation and Disposition
(truan rvom me fist bui
Number:—�—Deecrlmion: mn1--h fin✓
L Apemm Msigne Ininterest purtuant to Public HaM taw Se 4201(3).
3. The surviving reeuee:
L. The mrvrving domestic partner.
n Mydowing child withown years of age or aaer:
a. Aeumal pareml
5. A annoying Sibling eremeen years of age r older
6. A laMully appdnted guardian
T. Any part Monsoon"am of age or older eminedwsham in the estate and"a wa re doses] n reWonNig to the eleCNMd:
B. Aduly adderni l fiduciary of the estate.
6. Acro¢a mend or will who has exmwed a written netemem wasuam W Public Hands low seabn azgt(7):
10. Aced down officer of a county or a Public administrator apppnted Modern to lM Sontga ra Loan Proceduse Ad
ioa. Any Omer perm who Is acing on behalf of Me between and who has abnormal a wrltbn aWWe m pursuant he Public Heats
law Seaton 42(1.
li` \\rv�dree�r AA�U THREE dim bllmtind
Q_ryINJe hereby&I that the body of the decei does not wntein a Will battery pack, pmyer Mall, ndioadke lerho 1.
or mlloadme deyim and that any ¢arch mamnel¢wow removed prior W Me execution of this Autl H"V n Farm. Failure to remove
Nara Ibms poor W cmmaded may result In lean W idea cm Mory and crematory personnel.
—Nye aRum Met lnstruchadd hive been given W DOONNEEENNS 111A3
regaining 1M removal of any por WMend"or other thing ofvelw Mmfl any person ugning below or any family m Wrd the
lemaaedwNhe¢mpmerve. Pine VVlew Crernmenm
in not responsible he the internal of personal items horn the container or from the remains of Na dewesed.Panmullb sla In Me
1conal Month the remains will ba destroyed by Me cremation pwcWw and content No Mdevel aMr emmOM.
IM1Ve neeby auNonze Pine NMw
y"'. rium
R"maW cmm ow dire remains of Na leceMW.
FINAL DISPOSITION
le�pra(o �� u� oeaed IT Numaa a :
Name, ✓ Ib�on 4LKF Address b8 )p�mmyade., SIX- 74�-4Z td2
Tin damaged mmalns ofdereeaM will be al based of as foncem 12 qA
If far any reason lire pemm named More does my take p SOMW of ate unmated remains
Pine isWthomema give sM smna
me mmpnsm in F I 1 _byoalirory
New
in person or by engineered mall trom✓mre
Nnalie wall
+✓�� Page z d3
Dos-t6gagaev.o5rt5)
Authorization for Cremation and Disposition
rune Whereas)
Irvva
unaearammm rime remains are nncialmeawnnin tan mrm or estimation.
Plneylexoremamliom may dispow of remainam
an marieame manner smh as W scattering.
CREMATION CONTAINEWURN
�—
An are to be used as eonWner far the enhanced remains has been purchased tram
aN is described as release:
Me underaYnd that it the um is had anall to hold the annre Cremated remains, an scanning did=Wirer rtay he hand for delivery.
OR-
�V''� An um Is ca ur t yet pdhani Me undenland that if no um le purchased or otherwise N se pvlded
WWV""" Pine vis"CremBbflum all place the cremated remmn¢ in
a rigid bmareary container her delivery.
The AUMMaR Farm we amended by DONEENS NIKAS was ematedM
smear
Carleton Funeral Home,
Home. Inc.
68 Mein St. P. O. Box NT Hudson Falls NY 12839
and is signed Was IunINel director as w hisch toils execution.
Me have received a completed ropy of thla Agamemnon Tom.
The
b thea cwraacy and
camplact of the adeo aO Use an contained InlAluthorizatl n Foam anflid 8uMwlzelel Me s y
MMUMrlg a
signedbleu darts Ahaae . 20d
�� . Tf KYr/
- l J
Trk
mes'l ni/%Vre S}f f I l3 led I it-W n.�j /ara4
WITNESS:
DONEEN S NIKAS Dhei
R
i Cv
Amelia wen
COi few 08115) Page 3 of