Henderson, Alice G. Pine View Cemetery 8 Crematorium
Quaker Road
Quee Nsbury, NY 12604
(576) 745-4477 or (516) 745-4476
FUNERAL HOME;
DATE d TIME REMAINS ARRIVED AT CREMATORY RETURN TIME
NAME OF FUNERAL DIRECT q T 91Y1u REMAINS:
O OR REGI113TERE0 RESIDENT DELIVERING REMgIN3;
NAME: Az
AWX - - C`
_ T}ppf ..CASEp TYPE OF CONTAINER. '-�-
-
PLACE OF DEATH:
ESTIMATED WRIGHT OF REMAINS g CONTAINER
ko
PLACED IN HOLD: -
PLACED IN REFRIGERATION:
DATE OF CREMATION. _4-S 2ezP 7 Z� -----
TIME STARTED: 0 M - - - - - '
'� pi _TWE CO 1
PLACED IN RETORT; .'
RETORT N IN WHICH REMAINS WERE CREMATED: ) {` 1.Z
DETAILED REASON FOR RELAY IF REMAINS WERE CREMATED
FROM TIME OF ACCEPTED DELIVERY MORE TXgry pS HOURS
NOTE. THE CREMATIONLOG SHALL AT RETAINED -. . -_ FILE
_ - -
I
Ooomm" afsutt
o�wwxic Division of GIw.IG9 OF dTyn,,METEll D.%
rzoF o
"'" " Cemeteries
T..pam (518)Doi
Authorization for Cremation and Disposition
This AuMoNnegon Form must be, completed and wave Worfo"Ilvary W manni for memauon.
C
Data Ji e 1. 4 7,0 20 Number: q<
Crema1 Name: rflC IPfJ f 1
At alto/ d 4n06a, AJ PMee: Si9 - 7M17
CREMATION IS IN IRREVERSIBLE AND FINAL PROCESS.
Customer aGnNtl Out by placing Ne rmoim N Me M aaW and Me sundial hdtllnB Mere da into a eremak NemCarxlrMe
they are subjected to Incase heal and flame. The heal and flame will unicameral antl consume ewwrom V except born antlmi
whim am all that will be mnrcra mation.
rullowng creml flue crane wlll Wes reesooame elmrN m romove all of Me remains and other material"in Me oeral
chamber, nrtsmn,minimal bum and residua An nxely M Ion bashind. TM cremawrvwn.rprrem mademat flop rorelen mnlenmfi0m
the remains and Me Incidental and mrel9n m.mhel win M disposed Was required M law. The otemaled riewira wul be machaniMny
paudia eIWosmmt pieces and Waded into a Maalgratee roamer or our. CramM"remalmgenerallyere Pulvwdnwdumlino
,Adis fragmentis Npogalzame a,assumed gssue.
OPENING OF THE CONTAMER
The uematpy my only open Me container All the uncremeted human nne lot In limited such as b confirm Me
Nebay of the bed fled or to ensure that no materiel iSendosa]Hach Might injure aarookues An damage Me crematory praparly. If
human rental no ere deliver ad In a container which Is not su liable for cnmNlon such as common III or real Eel Me
crommemyowilIredulA Mat the remain,wmoved Into a suPmN comwo wmre It Accepts the mmano. me opening of
memrr w rm Inmate r or remo,alofremotes win be conducted before.wtneaa are All m done m pmacy.Am dignity AM modest.
GENnFCATON OF DECEASED
Name of Docaaed'.f—J�S�
(P l% �-f/ n fll✓ S (N— mwUl all �a, yse,va
lest Known Alln la � � 5 t_r� S �IIAfl 6�6 �'ki1lr Il F(pL0
Plate of Oni F ll
sac: Elm OF Asl DOB: 19 '{b Dale W Death: J /" 7 0Eeomrnew.glrc 90l b
OesMpbon W crnlreuwntairrer M wNm mrma Au be mrwerw.
Onit {f 1 Il I ,; � (X f-O—
PERSON IN
CONTROL OF G SPOS T ON
(Ponon(a)In coolM of normaBion,oMF ONE OF IM modampf
I Mahe are the elegance agentM Me de SSM designated In a cell or woman hatmrrent amwtetl pursuant to Public
Health Low Seaton 4301.
ae.
Me haw no xnoHedg that the eeoeased sexual a wdnon instrument punuam to Publ'e Health lew'sernon4201 or
sum wmainlne elribi far Me diapoamon ex his or usua ion and Irtrs are Me Mmn(a) hi pdwity under Pudic Health Lew
Sechen 0301 and hale Me right eWhedxe cremation of me remains of the depressed. appour ral.tlonstap lo Ma dxeased Is a,
ImIows'.
AI'rz 6 , e� ae✓t�
D05,1098-I(13ev.041E0) Pogo1013
Authorization for Cremation and Disposition
prmrtxmmma xaeepwl
uumi gesanewn: fl kd/
1. Apoa designated In waling pursuant to Pubic di Lew SMbn 421
2, The Fri Monte
2%. The summr2 domestic pennon,
2. My survimry mud eighteen yaam OF me or deer
A. AFrwing parent
S. Asuroving siblrp eighteen yearn of we or War
S. AlaWully appointed guardan.
T. Any pence OF)eighteen Heart of age or older entltkd to share in the estab and he Isere bound in Mentioned b Aa dexasw;
B. A duly appointed fiduciary N the eaten;
S. A ckae hieM or relative aTo"a downward a n sentiment pursuant to Public HeaOh Law SalicM201(7):
10, A brief Feel off mr M a county or a photo am Message imported Wrauant to the Sormate'i Court Pmcwun AFT
10a. My Mar gran wM is acting on bond a Me MdWdmj and Mo has MFmmma a wriMn MMment purser N Public Hear,
Few Seceon 4MI(7).
fem{M ALL THREE of ha r MlaMng)
SMe hereby arm Fruit Me body of the deceased 0.res not mnbin A Where bN mpxk,powN roll,mdbacBva m t,
or nai0xi'rn dr im and Mat any sum mabnals were mserea slot adthe container of may Au(horlxatlmForm. Fellunto nmovel
MaeeiWmmpriwWcnmadonmaymuNlnhambMemvW andymaloryp_n N. (.
5p Ams affirm thatmabucltans have Won Ivan m - )1R/) CC✓L7 � IE.
regarding Me ethanol many gmon�p Mwo�Mp Mire a Often"�' ,wypemn pnirg bmcw or arty lamas member of to
aemaaae w:anesropresem. Yfyll' V((u1LVu4.�yw---
ra not reagnslble for Me romoval of formi Imma from Me contamer owfrair Me remains OF my aeaassed. Personal Hems Fee In the
Forgotten or vnth Me vmmlnB will be aaelmrwlP,, cmmmdonpmcx a /aemnmt M raWavw Won cmmwon.
sx— Me hereby auMo.lae {' 1 /�l Vll C. la l,l�Pl4.r 0.�-n✓i��
an estimate FM nmtlna of the decx .
(Irv(g1OPnnotru f
wB hereby amnonm her named mnared dimmer to provide for delivery to and cmnmlm by an ahomm
nurses, If deemed revenues In the"in Ion of the fumnl Mntloq and W amend this fors In pmvlda the beer name and
address m such alhmab cremnory.
1911011.OISPOSRIOH
The pe NMdaw M mmlve Me crw wtamale OF deuamd from the cremebryls:
✓ om
eedrm...: s phme: ti/k — 7 (1 U 2—
me cr.narea reryryaMla2 ofosmoses win deplapoma mygfdlmn;
L( I ✓ r1 —Fb Lu m, la -
H for myrgve ryHn gfaOn names above pm mlb4e gmommMn of ee crM mmeFs,
( ✓IW b.ullwrMdroglve pmmnlmm
t�-- mP 1 by
inq n orbs repatenre melt , IICO t1ciep—Sm
m.s
OOSo10Abf Rev.041 Ppe 2Ns
Authorlmtion for Cremation and Disposition
I)MMI the MbwnBl
S t na M pG IMIMNere+aire an noldeimw wnnm lRObn acnm.rcn.u Y)/IQ Vlo �me barn . may eavoee ww,.man>m
an Imemova a manner,such as by.ermi terminal
CREMTION CONTAINERNRN
peas ONE attire mankind
An um W be used as a ran aine, for the oemalw small Me been [uMBeBE from
and Is eesomed as rollowa:
I understand that if Me um Is W small b hole the enme c,amemd annual an additional xgm whenever may be used for delivery.
-°R-
An man n"va,rna�I}Inve anden ndlMl nao//mw¢¢is vn,wseao1Nenmse v,omaw
Flea New Cmnalawm i f n Rv ✓'t [ cad ` y/mG TD r f�
nMewn V'Wltifllaw lG oemaena ramamsM
a Mid temporary montane,for defrvery.
ThiA Ferro was RZi fA<�¢n > IR/7 was eucNG at
( [ a-P P', .{-u uFal .j
bR MaiA �I +77g� i )Ay "At
and is signed by Me bull dlsnlo,as wlmew to Its exeallon.
Ii Nn nteret a complatw may or MIS AUMonaaNan Form.
TG panoni ) Ideal Glow ltlm me pelsoni In contrail of dlsposmon.who W signing thin AuM iU nForm,mnyq
to the wcurwr andcomplNeness0the nrfomugon contained In this AuMwlabn Farm and authorinls)the rosgohq.
Sign this 2'= �
]g ^ / `
nM➢IlIG,rau UGILrmi
MT ri." l5k-Pn Ac der Gnilai U ar l
riminarivini
were
ICyUassurn A.
row �
DOS-IN f(Rev.MMO) N0303