Wagner Jr., Wlliam J. Pena View Cemetery g Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (51U) 745-4478
FUNpRgL XOME:
RETURN TIME:DATE S TIME REMAINS ARRIVED
pi CREMATORY: p y
NAME Or FUNERAL DIRECTOR IVERIN —_ MAINS-
OR vEGNISTERED RESIDENT DELIVERING RIMgIN3:
NAME
Win - WAcu _-ip WW
TYPE OF CONTAINER - —EASED _ ly
p yPer ( p4l C"
PLACE OF DEATH; lyl III
ESTIMATED WEIGHT OF
REMAINS 8 CONTAINER PLACED IN NOLO:
PLACED IN REFRIGERATION: -- - - - - --
/Q,0
GATE OF CREMATION:
TIME STgRTEP. -- _
TIME co
PLACED IN RETORT L E _3�
RETORTryIN WXIC --MOVED'
X REMAINS WERE CREMATED: -
DETAILED REASON FOR DELAY IF REMAINS WERE CpEMgT - lII
FROM TIME OF ACCEPTED DELIVERY; ED MORE THAN QS HOURS
NOTE.. ENE CREMATION LOG y __
CnE E THE pep?EANLAT rryE Gi THE CREMATOIb
New way do,
we
NEWYORK Division Of ° O CEMM ES
IT
of pM510XOFCEMETEMEe
° One Chance,arm
Cemeteries WW11himmlnAi
Albem.NY 122314OW
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Authorization for Cremation and Disposition
Tb4 Authandmit Form must W cars Piston and signed prior to delivery Of remains far oremaaon,
Dale; M102020 Number'. �Giq
Crematory Name: Pine VIEW CMMaMO
Address: 21 Quaker Rd. Queensbury NY 12S0a pane'. C5197 -A[-vm
CREWMN IS AN IRREVE IME AND FINAL PROCESS.
Cmmebm 18 Ormed out by pacing me remains Of Pe deceased and the anrainer holding me remains are a c2nnumn chamberwllwe
meyareeube dtoilnemehellaMflame. Tlw beat and Rama will incinal and WMume everrylhing shape bone and metal,
which a M an Nat will M IM aMr cmmtlron.
FOUPI cremMon Me crematory will take overseas efforts to remove an of me remains and other material from the uematern
Chamber. but same minimal dust and residue will indy be let behind. The Mnday will separate lncidemal end foreign material"in
thenmain¢and theockbmal and forkign maWlel all W disposed of as squired bylaw megematedremaiMMnbeme iWIl
plmer frvol agment la laid 'raacesOOM and
kna into
2 mainframe container or urn. CmmWremainsgemrallyampulw WuMlno
um
OPENING OF THE
The aremakey may only Open the MMOimr holding the vocmmalW human Rmeins In limited circumstances, ouch as to afternoon the
identity of theawarded or to ensure that no malarial ie mclomd which III injure employees Of damage the cannot convert, IFhuman remains are delivered In a coritaMer which by net suitable for cam ium such as Prmnanial or mmm caskq Me
rtMMb will require that Me remalns be moved into a$unable container Were it accepts tM mmalne. The Opening of
Wnlainer or the banoferw removal o(rerMim vnll be COMucMd before a witmee and will M done in amody wM dpnity and re5p¢OL
IOEMIF CATON OF DECEASED
Name amewaMri William J. Wagner Jr. Mantel status: Manied
Lear Known Address. 9Aa High St, Athol, NY 12810
Piece of Diduch DeceasaQa Residence, W High St., Athol, NY 12810
Sex: ®M DF Age'. 92 DOB. 07/151191 wwafo M 09/092020 EatmetMWeghc 150
Daydream 0 mSk wntainw in whim remaim fill be eHiveree.
Nee England Cremation Wuxe container
PmSO
1persw(a)!n snlM OfNsp , hisiddif ONE OF the fNkwinp)
Iandiare the designated farm Of the decased defignaed in swill or written instrument smauead pursuant to Public
Manor Law SetlM 4201.
(i Mohave no knoutWge Nat Ne deaa¢ed ezecukdawrNen iriatluneMpunueMb Public Health Lew Sedana201 are
MII assuming diredlom for the disposition of his or her remain and IM are me mnan(z)having pMdry under Public Hea1m Law
Section 4201 aM he"the right to aulMrize default Mote remains of me dMrsaM. W[Our MiabnshlpmNedea WWu
bI1pM;
Wiliam J. Wagner, Jr.
00S-1 81(Rev. 041110) Page 1 M 3
Authorization for Cremation and Disposition
(insert Tmmme thleelow)
Number 3 Desornpeon Burviving Child
1. ryp"Zf b5ipnele0 in among pawl to PudiC Health Law Section 42at(31i
vr
No T4 suMvirg Od mO eStk punier
J. My Nevo us child eghtwnyean Or age or am"
0. Aaurcinng parenti
5. A suMwrg sibling egnteen years or age or olner',
S. A lawfully appoinlen guardian;
F. M lH y persou eigho w en yrsol%a or Older entitled W Share in the weber and cone out doae5l in removal W the aemaa
8. A duty nk)(Ornted fourth,of the aside
a. A dose bend OrMi"m wM as deal a wntlen Statement purarlanl to Public Health Law Socalndi p1;
10. Achief Orval officer of a county or a ad her niwtrab appainled pursuant to he Suroale a Load Procedure Me:108. My other person who is Sharp on dark If M the denial and who has mecu a written seemed showed b Iii Heats low SMion 4201(]1.
( "rt MREE of theblbwlrgJ
C Me hereby affirm that the body of the dece does net content a had , put pi sows fall, redidel emgad,
Or mortal dowdy and that any sub mal were removed prior to the exeupion Weis Au dzatlon Farm. Failurebremove
5e pdorb cremation met result In harm to Ne cremwory and cmma ory"mmml,
(Th
irvuea mthdinatm=nelewe gNento David Alexantler
reperdirp the removal eland personal prc}any at Other N'ng ol wall which any person signing powder araay lvnly member W tfw
dwMv, a whom to preserve. Pine Yew Cremate
is net responses,for Me removal of personal items form the mnteneror from Neremarna Of the eemasetl venonal items left in N.
capfeIner,or with Ne remains will be desWW by the cmmellon Pmceas and career material labor cremation
� .
Wle hareby maintained Pine Vlew CMMat0
revive,w--g
fo abmm the ins of the wcaeew.
I(al al OPTIONAL)
Wit hereby author"the named funeral director b provide far delivery to and cmmatlon by an album
mdory. if deemed maessary in the opinion Of Me funeral denuder,and to amend Nie term to provide the coned name and
addrNe Of such afternl crematory.
FINAL MSPOSMON
Tie preen aulM1onmd N receive fife uemeW remain90l Me dec¢wM tram Ne Cremalwy is
Name Alexander-Baker Funeral Home, David Alexander
Makes 380E Main Streit Warreartsburgr NY 12885 proms (518) U2 2085
Tre,oem remains w awenased tell W disposes or as fdlowr.
Return to family
If far any reason Me person named Show does not take possession Wthe cse Wmmdm,
Pine View Crematory N authmmd b give laueasion of
the mmarneb Alexander-baker Funeral HOme by aNiwry
in pemcn cc M regimg marl. r�.+wa..W�w WbBiem J. Wagner Jr.
ern.da
DO&1aBi}1(Rev. Wno) Page 2 of 3
Authorization for Cremation and Disposition
Iheblkwmgl
IMe understand Mat date remems am rat c;eim%wimin 120 date oraremation.
Pine Yew Cre�aronry meyaspO+e of Me remaim In
m irreMewek manner, sum as 4 Scattering,
nmdal ovForme ramwmgl
An um mlw used es a container Or Me uemated remains M1n been turbaned hom Alexanlerv8aker Funeral
pa<
and fide eaea;bee as lalowr
Ime undestand that lithe om h tW am.ub M1W the smm cremated remain; an addnonal tyre mnwner maybe read for eelvery.
An um is rwt yM furthered. Me uedemand MM dm um b Wrmaaed or oMewie,OrO ndr l
Pine Vlmv Cremab will pram the canard ramaina ;n
�a
a ega temr mnwner tar deliray.
This grrllroriaatlon Form was prmided by David Alexander was exewted at
Alexantler-Baker Funeral Home
3809 Main Street W n�ensb NY 12885
deed a Signed dy Me Nnegl iiretlor as vnness to its extri
Me have reverted a(OmplMed copy ath'e Audmrizedon Form.
The MMM(a) IdxMlbd below reran the per oings) In control Of dupaaalon,who by signing this Ar4rvrizaWn FOrm, aXasya)
W Mar accuracy eat mmplNeness or Me IMomution conbined In this AuNwbe Art Form are auNorizale)The forapoing.
Sian"thb 101h day W September , 2g jkl
Amy LL Combl:Baker k/�/.(l'!`,
W High St Athol NY 12810
wrtNE88:
David Alexander
10034 .».avn.wam,.r r.0
William J. Wagner Jr.
aw..aosa
pQ5f a8&e(RBy.012g)
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