Shippee, Eric Pine View Cemetery
& Crematorium
Quaker Roaq
Queensburyl NV 12804
(518) 745.4477 or (510) 745-4478
FUNERAL NOME: 03
C&4�
RETURN TIME -
OgTF fl TIME REMAINS ARRIVED AT CREMATORY-
NAME OF FUNERAL DIRECTOR OR REGRISTCREO RESIDENT DELIVERING REMAINS:
TYPE OF CONTAINER. - —"—.CASE ry
PLACE OF
DEATH: 4E)[Jy 44 4�P /(�_/-.1..p!-� I✓/y'-'tgIJKi4Nr-4.�4•v F-
ESTIMATGO WEIGHT OF REMAIN
S R CONTAINER,_ .I�S _
PLACED IN HOLD PP
PIgCEO 1N REFRIGERATION: - -
04TE OF CREMATION:pp /� - - - -- '-"
TIME STARTED: z -'-'
-TIME COMPLETED.
PLACED IN RETORT 0�1�+ �
-- y mpveD 9 --
RETORT IN WHICH REMAINS WERE CREMATED:
DETAILED REASON
OFFOR DELAY IF REMAINS WlRG CREMATED MORE THAN p0 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE Rno 45 ____
LVCRE NIREPE,IM R
TplF or THE CennTORv
� a>
Na.York arm
DN OFCEM CEMETERIES
NEWYORK Division of DlvseDo oFCEMETEPIes
y7Ah°F one C eartan a Plaza
OppCemeteries rB ,NYnnaao
e.l51e47bou 6
anseadennygoe
Authorization for Cremation and Disposition
This AU&mimNa Farm must bB c plN and slenid Mlor be Eenvery of remain for cRT on.
9/1 OM020
Caere NtmMr 101�
Crenaldry, Name: Pine View Crematory
Quaker RoeM Queen ebury, NV 12004 516]aSMP
AbdulPMne'.
CREMATION IS WI IRREVERSIBLE AND FINi PROCESS.
Cnermak n is Panama but W Mating Me remema of the deceasetl and Me mnbinu raiding Me remains i=a oem mcn chamber"am
May are subpgeL to Intense be9t and Name. The Will and flame will inO mmW add consume evmytl ing Gawp[bon and metal,
will are all drat will M left after crematlon.
Following vemation,the ueMMY will take reasonable sound to remove all of Me remains and other moral from Me operation
chamber but some minimal dust and residue will likely he left samInd. Thecontrary well local accent and Mal m venal from
Me remains Worm incidental and foreign material will be assume Of as rMuirea by low. Theme WdremainOwillbe snotty
pukml into small pieces and paced into a debgnetetl wnteinr w um. Cn 2 mainsgennllYanpul"Hri duntilM
single fragment he mognivMe as skele W I tissue.
�ENIMOFTHECONTMNER
TM Oemalay ran only open the coMiner Folding Me un-IXem human remains in limited uramel8n¢e. so& as to worm the
usually of the de a Or to ensure Mat no ormarlens memedin" might miun employees or damage the crematory Propem_ N
human nmaln am delivered In a container wmm Is not suitable for cmm,Mon such as cerem she l or ream Oekat,ter
ramtlory Will mgulret tMer 21m be moved Imes"fta wMalnerb m it act"the remains. ThecgeningMa
school came Mmgeorremoval M norma will be anduded More awiNazs and will be done In pawary,with carry and nWect.
NT F CATION OF °ECEABE°
Name MCer amd' Eric Shipped Marmi stmae
.
last renown mane.: 11 h4 Cazrk (ld � ��
a 12L5
Pleas ceMn-.
County Route 10, rinM, NY 12522
719/1901 9/9/2020 175
Ses; De to F Age: 39 006: DYe of Deal: EedmatM V.WgM:_
DBanptbn Of MkWn ainu in which remains all be dNivO
McDonald basic cremation Container, no interior
TROL OF DISPOSITION
(Poram(al M Nnbd Ordlspanbar. r ONE MtlMltll 9)
I arvWe am Me decimal agent of the dismissed deagraletl in a will Or w ftn instrument a[emna pursuant to Public
HeI taw aatlim 0201.
1 AOR- n
Pb� $11� Ig di lease no the dirsessron
that the demasedemaNs and
are MumentpureuntllO Pudic Health law SeNo L Ors
S WMainirl Whavve tarthetl aUthOtne his or her nremainsand ofare Me pare . havingirim under PublicH Law
Se 1bn42018M have Me tgM1tm author¢e oert,alron of live remains Of ter detain. IR/IQn releaaneM1ip to Me decMHd Ie aB
foumwa: Eric Shippee
m+•re
Page t Or3
OOF1393d(Rw. OSl15)
y Authorization for Cremation and Disposition
agg(s fee evowk gl
) \�lN undemtaWthMIn mrreinsarerWdain wlMin Iza EeysacremOm,
Pane New Crematory
ucn may diyars aline nmelnam
an] a ereble mentor.auto as by scattering.
CRE nON CONMNENNRN
agge ONE o Me Meowing)
An um to be red as a container for the command nd remains has been rural mar
and is described as f a use,
base understand time 11 the um Is that smell to hold Me ell channel answer an additional rigid con siner may he used for"hall
*F ^OR--
i,` An um is net yet processed WJe undo met it no um is qrc hazed a abnormal provided
Pine New Cmmmtory
pxmuwMl WII pearas the cremated remains In
a rigid s mparry antes er for de iaery.
Patricia Miller
This AaMwrs m Fare "aprwMed by was execadat
Brewer Funeral Home, Inc.
mmxm
24 Church St., Lake Lusame, NY 12848 P�uwrmixxrw
and is signed by the tunarel director as wrnese to ill mx tonmmnmxu
bWe have narrowed a compared ropy of this AuMaNeabnn Pomt.
1M parson(s) identified below Wam the person(e)in Plural of suspended, who by signing this Authorial Form,atficia l
to has accuracy and am plwne of Ma Inlommbon contented in this AuMorhal Form and euthomeads)Me barreing.
Signed b th
is f day of�lofi . M ill
A Co Ir..) 0.
d mid,, ag.�w
WRNE55: {/_fl\1!. Lll1WN
(TINES Miller
rwwamnew�.w, Rmva.sa+'A�+1
l RCGS
Eft Shippee
DOS-l8i(Says. IlSrls) Page 3r3
Authorization for Cremation and Disposition
prwwthwm fly UUOeIow) ^
Number: Cmcdpgm: 4_F,t.l.rl�
1. Apermn designated! M wrbing Wrsuant to Poole Health law Sediarril y
2. The survning epee:
v. The survnmg dimensions:paMer
]. Any survi child eighteen Yes"age Or O"No:
surviving
S. A surary string Meen rg g g years of age or older,
S. A goalgetlg. uaNi
T. An permorndeiM1teenwords
he age or O l4erentltlM to share in eNos eMaten and whom slae tlomal InreM4onabi p to the he demande
d
r. A duly appointed fieryof the e
g. A your friedmrworse whohas
snouted nen entWmm� ePublic HruM1Law Sect doge
10. Ai Oser0 a muntyPdsit
administrator approach sutbNos Stmmates Procedure
10a. Any therperWor who is aping on beM19M itthe dissected and wM1O ha9 ¢aecukN eMln statement pursuant to Public Health
SectNna2mn l
flrvmdl THREE o/Oe bWxi ugh
IA4e M1maby affirm Nat the body WMe tlecaaand does not contain a ball¢ry, battery pa k, power ci handsome irrylanL
or ndio¢cflw dance and that any such materials were remooed show to the execution of this Authorization Farm. Fallunbmnove
O INmapr WonmOonmayreauMIn Mrm WthecremaWryandmmrtgpn nnal.
� Its Pounds Will
LlMp elbrtn NativlNNons Mve been green to
regarding the rencend of any personal proposes Or order thing of v&us wMU any person signing below or any family member of the
Pine Vim cram"
decreased vnmas to preserve.
is netReponese ber Me removal ul pareorblitems from the coast from Me mains of the deceei wrtonal dome left In the
Come ner Or wlth Nos wool will bra Marginal try the mmabon pWcess and¢rondo ba reVleved after amoebae.
Pine wen Crematory
�IANe whites suNonze Wwmw+w
W crema4 hire namely of Me deceasi
Fill OISPOSRION
The parson aNM1o%ed to rewne IM aemfled mmairs of the decvM main Me v meWry u'.
Broader Funeral Hcmre. Inc.
Name
24 Church St, lase Lumme, NY 12M sioA 2700
Actions: Plme:
The cremated newins of deddeeed WWll M command off/day Mimes'.
b�f 10.� 1 ✓l �J n W DD�I I,GVYIL-{e.r'V
11Meny reason meson nametl a�Wre bxz noldke pou»ebn Ntle vareled remeim,
Pith CrematoryVery
seuMd¢ed to give posaesslm of
to remains to Blower Funeral Home, Inc Wm by Murray
awarrumrmy
in pason Or by mMMPdI read. Elk Shippee
DOs18904 Haw ll rtnnmmerui Page 2 of