Barcomb, Carol R. Piro View CEme[er
y CYOMatOYIUM
Quaker Road
Queelrsbury, NV 12804
(538) 745-4477 or (STB) 745-4476
FUNERAL ROM,:
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RETURN TIME:
GATE a TIME REM "A DIRECTOR
AT CREMATORY: y'/( b
NAME OF FUNERAL �IRECTORffvvO'�R����RACHISTERED RESIDENT DEL RING pp�5
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NAME -�_
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TYPE OF CONTAINER: AlAlll - /1Fro� 1 / CASE H
ff
PLACE OF DEATH
1. 9 t � 4reQ
ESTIMATED WEIGHT OF REMAINS 8 CONTAINER-
PLACED IN HOLD:
PLACED IN REFRIGERATION;
DATE OF CREMATIO
TIME STARTED: /E '_you
'.q1 = THE COMPLeTeCH _
PLACED IN RETORT 0 -MOVED! - — A�/��---
RETORT to IN WHICH REMAINS WERE CREMATED: _j/ O • � it
_SYE_R
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED
FROM THE OF ACCEPTED OELIVERv: MORE THAN Vg HOURS
NOTE THE CREMATIONLOG SHALL ER - ER F"^ x rive peamgn[nr r LEE OF THE
CREMATORY.
Oetworm" msYtt
NEW YORK Division of OMSIg1rc," EBoI�s
TFTSOF o < m P
onmNm Cemeteries
reach"'Almly. „l
do,over,
Authorization for Cremation and Disposition
This AUNroN w Form must bar complained and algna0 poor By delivery or nmams he cremsaon.
(pale: MIU2020 Number: 1013
Cr9nelory Name: PugwBu Canonical
AGderes; 31 Certain Road, OWenebury, NY 13809 Miami (s1B)TiS3TTr
CREMAnM IS AN IRREYEftBIBIE AND FINAL PROCESS.
Cremation is cheaper cad by Platlrglee m o mofvim dewaeed and flat,mdeilw Mdtg Me m na iMoe wemmcrl dlamtswTnre
Barry aresubletled to intense heat and flame. They MN and Same will Incim and mmu"m gMIK nup and nphl.
Welch am all tlwt will we lM abs cmm ow.
Followng crematlpn.IN vemMory fall take rMWade efforts to rel all of Me remains and other Miami@pn Me measure
Gwm car but some minim at due and real Oil Melly be left real The creel atory tall viderate Inndencal and foreign malenw from
meremeltsandtI Ino&nmlandt NnmaterialmllWdlsp ddasMWti blax. The=maledmmains Milbema na llN
evetua Into small peter am gamd Into a Senegal container Or Me Cm r im pneralryam WI"r well no
single Miami N mCOBnlvbm an skN iNNW.
OPENING OF TNF CONTAINER
The Teacher may only open Me comaNer bolding the unrremated human mmeilm In limited circumstances, such day to OXAMI the
IdeM oltbedeCeesedorbonsure MWnoma"alllrel AosN omlgM ln)umw loydsordalrlagetheoanatorygcyerly. N
human mnelN am delivered In a wnnlWn whim Is act sulbbla for cremation such as cwwmOW t or Mnwt wN Me
matarywlll "ulmtllrtlearemainsWmoM IMnasulbblacomalner Nlore It Ncepb NwK alm. The Beningofa
mnbmerormelrensMror removal of remains Oil beundlMeo before a wlmera and den be done In every elm dgnMand rearat
DENT FICATION OF DECEASED �1
Name acexNed: Coral K. S mwUl Sunni V. r. `
lust Nnwm MM1ess 1112 Cal IMe Luieme,NY 12M
PIas&om 21M Call 5NNL Vb LW e.NY lg
San OM OF AM TI DOB DINL1BfB Date ofDral CO'1M ry1B EarmabdW&gM Zf$r
Desmpdwt of stickle W nfalner in wMM h m ons wl N ON"i
(WWmat mftMeumanufadurm) MatlMus Auma WrcC and Cardbomd Cbrmtbl Comment
PENRON NLONTROL OF idil ITIgI
ry (s1 in mtbol or Moroccan PJ4&CNE Or me meta 1
I emMM amB a Segment aaenl ad the dKeasM designated In a far or women Montreal Pa Ma] WRUBM to Public
Meath lax Season ago 1.
o R-
ly/eJ INJe have no MwAedgs vial IN d wed eaealed a wiNen lnsmmeM uonuemro Pope MCMm law Sedlm 43o1 ore
N Mining directions for May Suriname Of his an Y remains and lose are the Nlsome having poNy,under Public NNM tax
y aeilbl azol and have the mini W alMluiae oemmmn of now lemim of Me dBreamd MylOur relarldo pto the dx is 08
fwlw
Care Barmmb
DOS 1BPCf(Rev 0.WIS PBge 1 of
Authorization for Cremation and Disposition
nnamnrmm mar amWwl
Humber 5 northeast A survival sibling n udefen years of age or Omer
1. Ap roon designated in wrNrg Trustees to Pubnc Health Law Section 4201(3)
2. The several Spouse
U. The survivi0g domestic partner;
p. Aury surviving aid eighteen some a age 0r Older.
Al Asordeve (Vrent
S. A SumNy along eighteen yeas of age or olcer,
S. Al awfully mounted guaNlan;
]. My pwe0n(a)eighlmn years of am or older emitted W share In Me estate and who l stare d OWat in relationship to Me debodandl
8. A duly ePoOi hard Nor of Me eatekl
8. Adose bled ore rats who has MSNbd a when sbtemenl pursuant to Publi o Health Law Saglon Hour(7).
10. A deal Mrel oKirer of a wun"a paid sure nlsbalor epmmd reswa 0 the Sr ncgab a Chun Pmmaure Al
10A Am other cerson Mo is asOng on behalf of Me doommed and biro has eeeCNed a women shaemmt tumbled W bubble H M
sew Shahan 42O1(7).
(mo,ILL Mil of me mawxyl
J Ads many,a at the CWy,of Me derea5ed does uM contain a M"M , Wtlery pad, rewnr colt, rhea live implem,
by uadiharLve eevim aid grandany such trial Rmm2d peatW Me eFcullon oIM18ArMwba4on Fqm. FMIUMWAmhva
Mayor Maybe prlw W wmaurnay should In loan W the cemWry sued cmmM p nmi.
�J IAYe and Wet researchers have began It W Robatl. genamme
ment hoq Me removal of any mRelel proaRy,or Omer iong IX vtlw whits any pamon egnin Wm seem humbly mambm a Ua
deceased wool to Preserve. Pircviery LlEMNium
is not reaponsWW larded mmwmr of paRMm hemehmre Meseason Me Rmmmamed teem. ParaWal hit MWUa
nmlCrer ewMMe mmmm bon a aamovad brdeecranmama war+ea ma onnedbe nbfaaad mercramMmt.
�wre hereby autlm PlnwN cre ae um wewr
W cremm ma emaim am.emmree.
FINAL DISPOSaIOH
no person tinned To Money me monad remains of May demmM bcm the Is.
Name. RORM I. Densmore
Address T Summer Avenue,Cal Hy 12822 sham; (SINimirB3ie
The aemaear mmeim a aashvea won for .a sympmDao fall
D ) Cp N f' � ryar ac
It of any ration the omen named ebm d rM boys gm waft damaged remain,
Probes,Cernobyl maNb6eEb" tide
os.urn.ry
Me remansTo generous Fuel Hem,tc, Michael
Rrw rewtwM
in part or by reg M& mail. Cad Serromb
nw»m
DO I89114(fti DI Pege2ol
Authorization for Cremation and Disposition
nwnyee fwinel
l.C./es Imr enaerennd band irThe remans are him banned.nmm 120 oars oinariarrvl.
Piro mCmrarDeum mry disposed of Me remains In
mum en
an irr¢Nerede manrer, wdo ee:rye211eMq.
CREYRT ON CONTAINERNRN
di ONE of Me Waning)
An um to be used m a oMbiner W Me nemebe remtlru Im man pumlwed man Oewnom Funeral Home, Inc
and is eeeoilM as hidden
WJe uMedand lM it Me um is too ampl to hdd the mini amntled remain,an adAMntl bid¢rnbirer My WW1 W ands"i
� `Mumknot ytl p[deud. WYe uWeMMlNetlfmun'¢punWredIX Warwaa ponded
PmevlewcremNodum eiu gawue venieled remen.nn
.da..ren
a mld amy welsh As delivery va -
mm�
This Anrt/rortretlon Form rrea proadond by FelM 1,tlanvnmm � "a emure0 al
Densmore Funaml Nome, ins.
6amravel
I Sherman Avenue, Lhhnh, NY 1=
and is signed as the Nneral dlrMw im WXr4as W id exablime urn
INJa have reIXrva]a wmdued wpr or be a AUNOAaNbn Form.
toaayaV lln Ne1
M[ demardmW Me lydmmaYon eanened inb Autlpr4tlen Form and BYderuld remodeled.
Skrcd Mb 10th darMW�
Canine Shemaad I j
2212C l Saes,Use lt¢sn. NY tYK
WITNESS:
Nobel Dea mvmmxan
1W10��
ua eundame
DOS180Lr(Rev.001151 Ppa3ol3