Ryan, Thomas Robert Pine View Cemetery & crematorium
Quaker Road
Queensbury, NY 12004
(518) 745-4477 or (51 a) 745-4476
FUNERAL HOME: cpttLo A/ - --_ . _ RETURN TIME: IeVJr1 _DATE B TIME REM4IMS ARRIVED AT CREMATORY: l�l
NAME OF FUNERAL DIRECTOR OR R'RON STEREO RE510ENT DELIVERING OREMAINS:
- _ .�.a4CFc.✓__ e4l KR S
NAME. ema5_—Fa fq.✓. - q/J /J
TYPE OF CONTAINET CASE #
PLACE OF DEATH 6LA' 4Tl/11 /4*PiRI lei2 _ .--...
ESTIMATED WEIGHT OF REMAINS & CONTAINER
PLACED IN HOLD: . __�4
PLACED IN REFRIGERATION;
DATE OF CREMATION:
.L.—.. _
TIME STARTED: _ I
a� — --TIME < M
PLACED IN RETORT 1J �y�{ II�n1 `✓'—
' MOVED � 5..
RETORT pIry WHICH
REMAINS WERE CREMATED:
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MOR THAN AS HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION G SHALL of RETAINED 1N THE - _.
D.vem..aormn.
NE' FORK Division of OrvnweepOFmenta AM
PORTVHITY. O H Pnnre
Cemeteries ,atagpl
Lacher.lSvlayl
Authorization for Cremation and Disposition
This AYUw tie Form must be,mmplord and signed prior Ad OeIMry of nmalm M crmMlo,.
Dare: Au`1 31 Last
Number OA
Dremate7Nam ichc l)lw cFvw Rv
acdreee: 21 K.g. RO vten.:S{8 ' 2
CRENPTION IS AN IRREVERSIBLE AND FINAL PROCESS.
Crammed is carried out by plant the remains Nthe deceased and the mnlelner IMOing the remains Into a uematpn chamber m
IMyare aublecred b atume neat and Aams. The hex and Name will IndnerM and Measures ewrNhing ewvl bane and mYal,
which are a l Met will be NM1aton cremation.
FaIImHnO usmabon the crematory edl take reasonable aXMa to remme all Of the remains and other material boss Pe cremation
clamber,but some minimal dust also residue tall away be Fall behind. The aematmy wit separate trial and foreign materiel tram
Meramams and the mmamal and foreign material will be&Wp of"reared by law. The oemord mi Mel be usecnam®Ilr
puroenud into small pieces and Placid into a designated cMteinsr er um. Cmrubd remana generally am puMrlssd until has
single musics t Is mcopnwble m akneYl tissue.
OPENING OF THE CONTAINER
The chair may only open Me mnlainer"i the urvcremaled human umaim in limited ciwmstanwa,won as to confirm the
entity of the diect onto ensure ma an ra a wherutl winch mightinryre employees or damage the crematory pmpere, It
human remains am bllmred Ina conminarwhoch Is nut subtal le for cmmadon such as wmmonlal wmnlal Muslim,the
consumer before
the
g.
un al toter for I2re will ice ler orrema al of ns W renmlm All bstnmvtlutled Wore a a suitable anon a""it on done in pnvany Meth diam�ninn of a
neror W w yassima d.
IDENTIFICATION OF OECE SED
Name Doomond'.Thomas RO dRyen Marital swws: O
LaY KmwnAWnu:71S7 State R dO Imt0 ,W
Pleos M Poe ,(News Fells Hasped, 100 Paris SL,G4M FAIN.NV 1=1
Sex'. IMM OF Agi I� 003:09/1011969 MASS ofpeea;OM612020 Estimated Val /sw /Ls
Oesapose oFsMeOmmmner in which remains Fail be delivered.
^c Codu4 TSe A
all OF DISPOSITION
(Pomn(sf incmiml c/dgxainon.miss ONE Arne/clbvnngf
I amAVa are Ne designated agent OF Me deaaaed duigruted in a All or wrlden nutmeat executed pursuant to Pubic
Heats Law Section FEW.
Me nave am knowbdde that the damsed exewretl a wnhen InsWment pursuant to Public Health Law Seelion 4201 or a
11 containing drecnm¢ter Me dlaposibon of he or me remains and Its an the perhat having fuel under mhlic Health bw
Section 4201 and Mve the right b Materials cremation of the remains 0 Ne dewaud. Wall mholonshlp to the deceased Is as
William
`(40 ll .mr�.p�7 mu
DOS-18MV(Few. 04120) Page 1 of 3
Authorization for Cremation and Disposition
pnmrcdmm M.wwnw)
Number: radii I) kkL
1. Aperscn Emlvnatialm vvi pursuenl W Publ'e MeeW Law SmEon 421I
2. The aurvlvtng apawe:
]a. The fors inq dmyOWc partner,
0. My mri child eighteen yeva of age w olden
A AsuMOng parent
S. Asurviving aiblirg eighteen years of Ago or di
a. A IMMY$pointed guaNianl
L Any parsonlq eighteen rears a no or older.nt W sham an the matte and who!Were do stmrNa Ghop to Me deceema:
B. A duty apaptded fiduclaryal the estate;
B. Adoes friend or d9rve vow has esscWM a after statement tear roped to Punlc Xadh low MClon 4201(7),
10. A chid III otbwr of a appear or e pudic Administrator appointed pursuant he the Sumpek'a Court Procedure Act
too. My ohm careen who is scat no on behalf N Me demased and who her Ox Nd A'man tl Wmma pursuant W PUMC Health
Law ffecoon 42019)
IfSQr/ lrAa�u mhREE a he mm"ilg)
1 IM1Ve hereby e ,m that the lardy of Me de "W doer nor W,n a bankers. emery pack. power MUL Israeli Imgam,
or redloaaMlve dnice.Mh$aenv wrA mabna6ware removed prgrto M$vecunon otter$aahonnYan Farm. TNlmemnmus
Most
reconstructions
prbr or mmallon an" result In ham tithe cremabry and cm Mary"monml.
late affirm reconstructionshamLinLs
lans m been given to M is k
r itregarding ha removal a any p rapper �yapMy o1ro`Mahxv a1//IvI$lue which env verso^Ypning belua'w MrfaaNN memM,a Me
dereaaedwtaneempreeelve. Y td'L'") L'k+Yr ----
1s not respon ihW for Oe mmoval of personal Items M1am Me Ccdelner or from Me roman¢of this demesed. Nnorul Ibis left In the
opoper or Wth Me remal im M ll be dad od bylrtb cnmatlon pmmss and 4nma be re m moved after craaton.
MAN,mrsby auMorW f y'U Clta YMa�
1 by mmeK he mmalro of the deviated.
(OPTIONAL)
4Imm hereby ammo!¢,the named Nnml dlredor bprovide for delta q to alsocremi by an alternate
ry1If deemed mm�ary In Me opinion of the Nnmal dlrecbr, and to smell this farm to provide the COMM name and
address of eltmmte cremabry.
FINAL DISPOSIT ON
The"Me, andi W remlve me MMMad MMalna of Me&WaW from Me ceper"As
Name: w-n K J u k
Mdmm: AbAL - �# 6L J.,6a Or wY h& 31 prone: -fga7yrvwq
The rsemaWd remains W da SW ado be dbpasw of u falawa:
J. Adktf p-L-.ha
ifMMr:e nnpMecnnom $lave does rot WM oaemakn Of for
Rm Ane.
pU rpeanfar _ , I eemlarbedW eft.w 5skalm
Me remains to C �-� � FNd —T� q by tlMNW
in perean orbs replarered mart T( m t2 - 21a
T p...p.s.n
DOS-18% f(Rev,Mom Pwa]of
Authorization for Cremation and Disposition
(I hWwM9)
Me understnd Mat tl Me remGna an anthill All 120 Maps of wmtl
mardintrosemtnerem.maln
an specie manner,such as dr sea Mg. lar,�etmwn
CREIMTON CO MNERIORN
(�ONEaIMelwMowing)
An um to Ee used an a container Air Me mmaled remaNs has been purcMud ham
and is deauibal as follows'.
IMS understand that n Me um Is M bar to hold the enure crelneted remaMe.an Wool lgye xn mar An used Im mural
oR
' &Mom ienmvetpuN . IAVn anteroom Min rcNum is Pure SW or olhervAee prowled
POW Vim CnmMnum will plain theOmuNd MWIIB In
Owww"Ancurs
e rigid temporary container for damery,
This RUNOAtatlw Form was croaked by Mori- Tht wa6ee0JM1tl e1
M�+owa✓..M
L8rld I 5'i H l4 Ny lZBf�'
and is signed by Melurerel director as witness to be eMemnon.
IM'e have reulwl a commuted copy Crute FutMrlaallon call
The
Me accuracy and ccompul�msts of Me infomullon control
ldnb bill Aumomal Form anas.moriities)the forma lnv~(s)
signed MN delta 20 20 ZO Blx� L ( 2 tie, rV`I I744
vm�1xl1Exs: L
Am
k tl.
OOS409Mf(Re, OalRO) Pape0ot3