Salem PIRe view Cemetery g Crematorium
Quaker Road
Queensburyr NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: _ _ AseW
OgTE 8 TIME - --- RETURN TIME
REMAINS ARRIVED AT CREMATORY:
NAME OF FUNERAL DIRECTOR OR REGRISTERE
DD 1�f11J _ Z�MOIn
RESIDENT DELIVERING REMAINS..
NAME --
- aened NA sA�Eh __
TYPE OF CONTAINER -CASE X )off
-.MN14Mic _ d — ----
PLACE OF DEATN Ph"P fZ��t.
I2
ESTIMATED WEIGHT OF REMAINS fl __ (Z
CONTwINER py
PLACED IN HOLD: ._...___.-_.. �Ad _
PLACED IN REFRIGERATION; �--
DATE OF CREMATION
TIME STARTED: _, o )DID
PLACED IN RETORT - 'Ll'19- T ME C
6LprI I/._.. MOVED: _ -_.
RETORT IN WHICH REMAINS WERE CREMATED:
DETAILED R 'S .... ��,.-,
DELAY IF REMAINS WERE CREMATED MORE THAN p8 HOURS
FROM TIME OF OF ACCEPTED FOR _IrF[
CEPTEO DELIVERY
NOTE, CRI!MATJON LOGSHALL o[ __. __
ne
M
n THE vERwrvENT FILE OF ME CREMATORY
er,State
EWYORK Division of D.p.M�eMnfegta,.
STATE Of DWIVONOFCEME lE
OWORTONITy. Cemeteries annobn Avence
l malmady,:MWasm m
ypoe
Authorization for Cremation and Disposition
This au rondeNon Form most he mmplN d and signed labor Mllvan N remains for cremaRon.
Date1L 9, 2D2D /' Number top
Cremalay Name: �lrr LW L.✓eral 6lnsu
Address Oudk�✓ I7d , uSadeat b 4YT lPyrone: S/8 — 7YS=uU7?
CREMATON IS AN IRRE ERSISIE AND MRLL PROCESS. i p
Cremation is anmd old by plating tat remains of Me deuaad add the container boating Me a cram Stan chamber tore
May am sublarkd so intense heal and game. The hi and Game will Incinerate and eoruum ewrylMnq except Gone and mNtl,
whi are all that will he MS after cremation.
FollowmgcremaroM1 Me crammory vdll whe rewaymbe MaN b remowe all N the remains and other material from the rental
chamber, but awns minimal dust and residue Wll likely he bit trawl The oyormory,will saaiaN lnekemal and brelgn material from
the remains and IM Incidental and foreign malerlal will hedbsc d Nee regulmd 4 law. The uemabd remama will be mxhanldelly
pulvariad mio small phase and paced laid a wedgmared mmeiner ch urn CM MW mmalnagenerally are pulwN"until no
.Ingle fragnxM Is mcogmssble as mall Nasue.
OPENING OF THE CONTAINER
The aemabry may only awed me mnleinm hall Me urrcremased human Panamanian gm Iced circumstances, such as to confirm the
identhi Ore amended or b ensure Met no materialis shouted which might injure annual or damage the front properly If
Model mmalne are dellwred In a conminer which Is not Suitable TO,crematlon each as premi or rental caskX,the
mi will require that the remains be md Inuble container bare it meal Me remains. The opening of a
rmer ove W asW b or Me transfer or remowl of bounce we be concluded bekre a wnrreaa and win the dda in privacy.AM digmly and respect.
IDENTIFICATION F 1
Nammo Oeeeaa' rna ll'hq. L. SM. _ I tfYa wall Mal rv�
Last Mom,morass 17_ Prea.r > to Cia.lway rt<sTQzw f CrNI �n & INH
Place of Deaf: /1- .-Matt In ale, le✓raie11 F� riS fare Q I I% Ny iay
Sax: DM AF Age Jr d COS: Z12.21gs, e DNewooM: I ice" ENma Webht L
OeamplianNeskevenmin.rid which repairs won be dellwM.
YYIaldlaxeremahm rn ( e - nlupo l h� rro
PERSON IN CONTROL OFOSPOIDION
(radial in contact a dapoLlbn, rattler ONE of Mer howeirlN
I air are be wisgnamd a gent N Me mowed despmlM In A will or xnhen inNrlvnanl sealed pursuant to Public J
Halm Law Seclmn 4201.
StIAw,haw no knowmadge Nat the 0eeaad executed a wrNen matmmew Pura t to PWIC Health taw Section O201 cea
and direccons be(he accustom of has or her member add Icwe we Me parson(a)formal moody under Public Health taw
Section 4001 and hove the ngm to Amoco,cremation admonishment of demamd MyMur emtlomMp to the deaaaw w as
bite a:
ICM
DOS-tSSBI(Rev 0I Page 1 of]
Authorization for Cremation and Disposition
flmxnrmmgenat w) I
Npmd.r� DeeosmMn:_YI US ban �
1. Apal&m malsrmled In Sena 4umminl to Pol Haven Law season aml(J):
2 from surviving spouw:
L. Tim surviving domml,deal
]. My pool dllld eighteen yeam of age or hi
0. ASo log parent'.
!. ASUN..my aielirt Vithmen yeas of no or olden
B. Alsal appointed Moral
]. My mral ejhIeen year,of age or ddm entitled b seam in the estate had'he lwhare broad In nlatiovbi ,to the dewsw
d. A duty appealed crudary of the emme:
p. A dose"no or misive who has mubd a wander,Klement pure m Public Health Lew Sei4201(7)I
10, A chief pool officer of a cound"a paid administrator appointed pu moans to Me Surrcgss s Gaon Premdae Ml:
10e. Any Sher person wed is send on behalf or Me dttered and who has executed a women statement pursuant to Fudic HwlN
taw Seale dzm(7).
�1`flnXS�I1(ALL Mal mine bowin0f d
'yJ —Inge mercurysfirm that tea body of Me demanded does non rental a oaten. bal back Marche pull radl all Model
VVV or Somas (Motor and mat any such enamels"to remowed home We execution Mtse Authorisation Form. Fallurebmmove
the" dame prior memadon mry result In ham to Me roamerd wmebry pnona
15 Iiwa Afrm mminstruawareva men given to i roe �. IV iKG-m
including Me removal of any porno Mardhe�m�lrgavaluawlrlcnJJnr Mnonagnr�pesLoaw any ramNmamol of Ma
damased wishm m preaam.. nP- VP {J ( X� m'cu Ur ( t� m
ra not normaidle for ramwal W personal Rama from the mneher or Item Me move lre Wore deceased. Penonet Ipms leM1m tea
Uinwor*th Memmerm Mllba des ed by ma cmmslm emcees end canned par�redrvad after cremation.
/'Y)A owe hereby Mdel fne VIPU) � �TL /% f1m
Y nream r
to come.me remains of dedseaad.
Iurau OP110NALf
less hereby summers the named funeral murder to provide for delivery to And crema0on by an alWrni
nmatory.0 deemed necessary In the opinion of the funanal mrebop and b ameM MIS farm W provide the mated name and
eddrese M Such allemam mundary.
FINAL DISP35111O11
TheperchauM wJ b texlve Me cremated remains of Meamood ran Mec^wy'a,
N... rAutrlhd eraj aryl L - ( f-0- 4 ,r�
Address: T Y Pe PMtm'.� N- �1 V DI— /J
ma chamber headed s Mme ulq aepomtl o�rgloMowa � . �L /l
w q
dM V0 Wpamen named eb-wt9pp���am cub posseWon b Me mmsa]AnuiM.
[/l-P Ul P(A� (�VeeM Q �'DYI (.(-YYl Is awtmud w Mae pmmvmdna
" remember c4yle era! metT✓t/�. b delivery
In parch or by"Mai reel. "7n I der
DOS-1age-f(Rev. wlm) Pear Fdpesms
Authorization for Cremation and Disposltlon
rUa�m.rouaarr�
.Ui MS May uMertland Met if 0w nmaens are not cleared MtlM 120 days of downward,
may names a Me dimension
an lneblevable manner.sutli as by s®firmi w.wu d
CREMATION CONT.V NENORN
rigger ONE011i olhwwnp)
M um to be ward am a container Mr the mmtlM net we bean Wadmmd from
and is weauntee as saeed
'Me Mderated wf XNe um is Coo small b hard Ne errs mmmtW remain., an addatmal Xeld container may W used be Mari
OR-
9 R_M um Is mf yet pumbe . I AND understood limit X no vrnIs Wntamad or otherwise provided
Pine vim Commit
Iw�aoMwd
will ONp the cramabd remains b
a XBld 4ordi Container be defvery. f^�1 ) � (I f�,p
This AUM ZRUon Form was pavendd by '�Yt 1PP /1 �` • 1 ' l "a".doted at
lC n 4 Y1 I men
Tnc
r.n
and la saheb by the rm.ra dir.ctm an wMNw to is e.edadon.
Ma have rewired a mmpkbd way Of MR AWI adm Epm.
The penen(s)Itlantffl d bebw Ii the penmla)In demand of disposition,who by signing this AuMomatlon Form. NYses)
to the accuromi plowman Me NdwmNlon contalndln q,b`ANhwbation Fomr and suMoking)the fwepoing.
signed mis dw of �P 21)
P W ear F
" ridn's i
�rz
DPS.ti(Rev. NOW) Pogo 3of 3