VeRose, Arthur John Rine View Cemetery & Crematorium
Quaker ROa(1
Queensbury, NY 12804
(510) 745-4477 or (510) 745-4676
FUNERAL HOMC:
DATE BTIME REM -- - '- '- RETURN TIME:
AINS ARRIVED AT CREMATORY: _.
J
NAME OF FUNERAL DIRECTOR OR RECRIST ��ERED RESIDENT DELIVFgINp REMAINS:
NAME _
pprf��:p
flr-:rt`P Rush._. CASE9 `DOD
TYPE OF CONTAINER `
PLACE OF pEgTH
FITIMATEO WEIGHT OF REMAINS & CONTq NER___ /1 / 11
PLACED IN HOLD; 1�. (7ZOYA..
PLACED IN REFRIGERATION
DATE OF CREMATION:
4
TIME STARTED: TIME C--- J� -
PLACED IN RETORT _ �jfl9'('1
RETORT II IN WHICH REMAINS WERE CREMATED; _ � �+��/^�
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN VD HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE THE CREMATION O L o -. _... A -
e RE E m x E v¢xM Lxi FILE Dp THE cnemronr.
FS
OIVISIONOF�EME1EMp e
One Is e
ygmpIII
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71, one:Inlnlm
NEaMY00.K Division
Of
_ p 1 1p.Gld. I Cemeteries
,lion and Disposition
ne ewMa pam m aMRMY d lemelM tw c..mMlu'
Authorization for Crem
on Folm most as wmpwl a 5�
TF4PUMONa11 Nw!!N
DgiriV2020 518 145<417
paR: U&,, talum glee'
Crosse"M pam QOneOabu ,NY 12a04 n doacremaUM dram emeui.
ese 5l QtlgwM d. ndalMmeremai s� 1 ,anumW
N& DFgµ �'E�. aq Me wnldM� yp¢oNume avaryMn
BLE Pa d ae¢9 Nme WllbclMlal° ¢cremation
N lg ee,lBBEUE me ,,a dear mat al lloI In eSellRm
cttEMPTMscd¢nse Mala my plairm MMm¢- ^MIMs1eM 6e 1¢1ndMnlalaMlc[ei0 main
crem IIdMe as Wlt{
ImMnsuslMaaa etlel clMRo Tne nemal¢'Ya MnpsUry 1peaU tl sp ade¢ppwlo RmWT,eMawa�py will sepere
no
May eR an
cel ti1aMres111Ma1Y day FeN� ma1n40eneR
wlncti,Hell M~enon,Va Mouncl .dw MIeREemar reyMlaw
tlMe �mala Mna Rs tmor wxl ycon�IXYm.
OlwMya R
BBWlsmlz p2'la¢nml Walo�agn� aeei0na4d xnla esb Md`n"IM
M¢RTeim and Me x
"wenal9me5 RC WmasCleNaxalWlM1asw. Mnalns-m ulMleam je MmWa sremainderpadedee
Homan bye¢e o� Me d•
ONC It FM alseIse wadi mwMlniwe emPha$Co M ena NPe
wdaineonoMN9 Me unua bl cnmsMnsuc yR namalw. TaegcpeMq
Tnecyll", Mayage, msureNet nl Wnunot 50 w Mmalpa! it d, OMPnvaC.WM
IMn1aY CIM ndassaell¢alea Ina ¢UM, ardsII Oe oN' U bab
s�"mmainsaw RgUlre Membe^I OIre sMaa lmoa es��Meawawsee Martine'
wnle'mel al Me vam �IN ve ManderessuI
�_�_ofi4E3fM grthur John Rose
same Of
. De¢easea .13KMariro Street Y 125 4
12B04
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n
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ed
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eaecwoa Wltl¢^Inswme I6INVI RYMssmp
Mal Me aec¢a answer u
jeya. MY
xnWMae° ddadrom mama ar4la aeM WI
IM'e Mve no Mndare reTai^° _ ,_e,. Ro`
winwM 4201OM Isom KKNe aisPmal°" -rtllu�'..
�csm,azol arpna+e Me a0mM aulnonu¢+e'"'
tot
p05.IBB61(Bm. Mac)
A
Authorization for Cremation and Disposition
Hawn Imm the Lou below)
Number y12 oes«iaioMS r.1vi S u
1. AarOontlegmWinw MPuweMla PudiclMHnlaw5etl1cn4201(3)'.
2. The surnnng spoon:
}y TM euMung dOMI PaMer
S. Any surviving chile Means riots a she or drier
4. AsuMaing perm[
8. tr i[Y slavered A xrs ae2e or Order
r. MY prose (s)egntxn Yeah Of pry or doer entered to sham In Me xteb eMwno iLaR contestre4wrbhryN Me decrease
S. A duty accessed fiEupam of Me estate
g, A does lrkntl or means Who lie same" ew^He^atalement PursuMtlP Pu0lic Health LAW+Otlioni
10. ACM1lel final oHmer olamuMy of PUMic ad ton6tM«appremad Pursue or b Me Surround's Coun Pmmriam Atc
1M, Law Seetiogn 1301(YloOaaiy Pn MhaHoltM deceae¢ri antl wno nes azewledawrNen sNleaRM pureUeMroPuaICXNHn
G ALL THREE a Me MNws+nul
'A _Mye MmEy Aran Na the body of me riewased does body W^dma dtdry.naHOry garb.Wwerreu.Mloecnve ImPlanl.
Or m ioaNve deice and dal any surli matanels Were removed Matrotiv eaeuNm data Autlr«Iaarbn F«m. Fallumm mmme
1Mae rosin Pn«m nemau«r my mean In ham m by,nNrr0larY and emT q personnel.
� fp�IMe afirm Na instructions have haw)Meanro
Sjersh�A. PPhhilo
an«tlbp avaWewhlcn any parson signing haloer«eM IBmlly meml»ra Vn
mgerding Me mmWelaeM Pma^al Proparlym Pate V16WCromal0fbm
deroas J wisMs N Mexrve. " Panon0l Mira IM inert
is xt respo ieni for a mmoaa pry m9nel and,farm ate deal Or hMn me made Pl lnB dxeaxd
wMelnn or wlm mee remain win be rixvoy.e by had mamas«wares.and cannot by mandated after ammatwn.
Pine View Crematorium
� sa.Q- Mw.n.rehy aumarla. ,o.,,..,rtm
Ie cmmam m.mmalna a Ina e.c.ased.
f n'er monosuu
Mary nneb)90MOI aNa named Nnaml pPrxlaror dalmery re and cmmauan by x atremrta
mmerery�rydxmatl nxxaary In:ZodMo odyM1alun Lab ad]m emeM Nla brm to provide the contest"am
and
addition a Such Shamed rnmOtam
NA SPO Snn1N
inn Perso uthonred to receive tlm«xnelN rSmaineaNe damsN lrmn tlw uwnOt«Yie'
Name Regan DOnnX St If Funeral Home. Semh A Phib (518)]92-1114
AM'sm 530 k Road Cueenebury N`/ 12804 Ph«m:
The«amid in on a Mmwd will be dlspmd a e as Mh
To be mlumad w the wile. Cynroie Rosa
med nave done rnt miry llrMxauonaNa conmed mina".
XM BM veal NepnSon^e of turnaround to Gw"amndedof
Pirx nova Clemarohum
Regan DennyStafford Funeral Home M daNery
the mmalxm n,,,.vw..x.wr
Aramr John Rosa
In PgrOpl or by mprelemd max. pymyvs9
Pegg 2 of 3
O Idbdlu1(Pay.04120)
Authorization for Cremation antl Dispositlon
0oL She rwmw,,,m
x A�- Me ummtene musing nmei,w.re nildaimM eimin ug d•ro ammMon,
Pine Vlaw Cremelafum
an irreAavade manner,soon ea by eezmalg, alww r may asps¢ofMe amine in
r�c
or�mm¢�a•
�M um ro m aM as a wnmlar W has u¢mnM maim has men pdyhased hdm Regan peonS y taRsxd Funarel
and is descnmd as hoboes:
Me uMearprq that npg an is to eyes ro had the ache pgnq¢d remena, an
MOaienal raid oanmnx mey m used st da y.
-oR-
f(�f M um by nod he pumne,adf MISu ,M,eene,May y no um w pv¢huM podmwtsa pysidM
Pine View Cra dn"W"m
w�Yl plemth¢¢remated minim In
a dgN tampevy o»a'vyr b dtliuery
ne AUMayaoA Nash"a aprMd by Sarah A. Phib
R an Denny SteRord Funaa Home w was eeerod as
83 Dueker Road,Ou se�rr¢hury, NY 12804
d. .ww,.arN
and be apmd by she Nnerel dlreMrae wilne9s n Rs eaeMiwb, '
INYe hero reanytl a wmpleted COPY Of this AuleorhNon Finn.
The prainisi Identified below h are IM h
b the xsuary eM cpmplaeneea M Me lrilormmaatlon iinaladnb YPos Awlsommedin FOMald eM authMdaatlwr FoM, eXesgsi 1
SIgnM Mb yM daY ih Segtembe ^^lq tlw breading.
20 20
Cynthia A Rosa
13 Kathetlna Street, pueenabu NY 1280 W. t t rpCT.
Serah A Ph'b
12889J
Arthur John Rosa
mii,wa
oarzol
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