Carter,Frederick Pine View Cemetery & Crematorium
Quaker Road
Queeasbury, NY 12604
(516) 745-4477 or (516) 745,4476
FUNERAL HOMe:
----_AAOLtFF
BATE a TIME gEM -' --- RETURN TIME.
gIryS ARRIVED EO AT CREMg 9
NAME OF FUNE CRY
RAL DIRECTOR OR nEG"'STERED RESIDENT DELIVERING gEMglHg:
__..____BuK. _.—RAlksFf..
NAME. mix
w _ _
TYPE OF CONTAINER:
CASE 0 16M
PLACE OF DEATH:
ESTIMATED WEIGHT OF REMAINS A CONTWNER _, 1I11
PLACED IN HOLD; -A6B
PLACED IN REFRIGERATION:
DATE OF CREMATION
TIME STARTED: _]+yam —
TImECOMPLETED.
RE �
TTRETORT ar._movepo: _
TOR
T # IN WH1CH REMAINS WERE CREMATED:
DETAILED REASON FOR p kRE _
E REMAINS WERE CREMATED MORE THAN AB HOURS
ELI IF
FROM TIME OF ACCEPTED DELIVERY.
NOTE THE CREMATION LOG
I and we are the person(s) his iq phmily under Public Heats Ides senMn 4201 and have the right To M aohae ..
cremation dose remains dtha eemaeW. My*urMadoah)ptoos des WMMfdbwa:
(Insar/mmtlreM#Lelowl
Number: Descdpaon. tr -
1, A person aesigni ted in writing pursuant to Public HaMlaw eamon 4201(3):
2.The surviving spouse:
L. The arvHirg d(mestc pamper,
0. Airy surviving 614 eighteen years of age or older:
4. A su"Wing parent
5.A surviving siring eighteen years of age or olden
E. A IawfO9y apposed d guardian{
T. My persons) eighteen years of age Or older emitted to share In the adds and who Idare closest In
relationship to the Michael
9. A duty appointed fidutiary of Me berate:
9. A close frond or relative who Me executed a wntlen arderant pursuant M Public HaM Lm§4201(7):
10. A chief fiscal Officer of a county or a public administrator appointed Pension W Me Surrogate's Court
Procedure Act:
10a.Airy otter person comp is esvn9 on wMn dose deceased end comp Ms exec awn n statement
pursuant to Pubic HaM taw Pi(7).
( (ALL THREE of the Adorning)
IANe hereby aMno Met the body of Me eeceasnd Mines not contain a behery. WM peck, power call,
rerdoodave Implant, or neiadve device and that any such moderate were removed pror to the ewcAion of This
ANMlbalia Farm. Fallure W Offleve Mae Om phe b crematlon may rauh in Mmr a Ma cr malorY and
c doey pandushe
INYa hereby affirm Met inshuchore have been given to Mn+'w 6afvunet
regaN7gl The removal of any parwrel property or other Ming of vela yr i r am person sursong l ebw Of WrY fida y
madder of the discovered wanes l0 preserve. loe�an'vnereiT ] 0(2h4![A V is not
responsible for removal of personal items TOM Me container c from Me remands of Me Uncommon."m iiin.w
writ in Me container or wM Me remains will be Oatroyod by am cmmaach process es
nd oved
ter cremation.
MNe therapy auhORWO n 7+>.T,er an anmete the
a a of 1M chasi
Filled g ON ^
TheparserMTazWMmc*5MecemeledremainsdMedecodedacnosacmffa yw:
N m oa: /a/NB/ AA /r
Andras:/ " azoe col ry / alb ,��zzf'/ panes: t7�7SJ�7Tf"
Tha cf /ea nerreia aae/deed win tea daaad Of afdloxs:
J-cvQ,a� �6 ✓�f1.7
Hfor any raean�da person MmNd abp"e dca^°t bke p°aeaM s dose camerae emmns.
rmaerveamw /i CL /rdfnw.e}Fs/ is eby Magtlto giveP Or bynoIddpd part
/4J py rofrveryMpemon ar Mraietered mail.
paa'wlws �l
r . F�Da♦1 //a?>T6
ope-,sea« flow wnm
r 4 r.. o saddens
Authorization for Cremation and Disposition
ra.e.m,m,
Ia,Oavaeia
...aoumm.w
Tha AMorfasbn Farm must bs mmph amd slpwpith to deNwacy of missilesfor Macmillan.
Dale' �J
Clemsmry the LX4
me: ///'y�� LL 1
Addrea: al LAnW d'K s cadi'ti .V Plgne:lS��/�'S yy7,
CRI.MATNRN 13 AN IRREVERSIBLE AND FINAL PROCESS.
Cremation is Worse on by plating Me remains of Me deceased and Me container finding Me remains me a
Mernation crambei where May are subjected M intense beat and flame. The beat and flame will Mechanism and
c0onalumn) everything except bone and meal, which are all Mat will ba left after cremation.
Following cremation, the cremarory will take reasonable efforts to remove all of the remains and other matelaRrom
Me cremaoa chamber, but some minimal dust and rel will likely be Wft behind. The cranial will separate
incidental and foreign matenal hour Me remains and Me incidental and foreign materiel will be deirowed of as
reauiretl by law. The crem2tse remains will be mnemonically Pulewthed into small pieces and Placed into a
designated container or um. Cremated remains gemrelly am pulverizeU until no sumo fragment is
recognivble as skAWl Saaue.
OPENING OF CONTA NER
Thecrsmatory may only open MB consumer holding Me un+mmeretl human moral in timiatl circumstances, such
as W will Me identity of Me dra seed or to ensure that no rretanet is endaed which might layers employees or
damage crematory property_ R human remains aerdeMerse in a container which is mat suitable for cremation
such a a ceremonial or rental caekel, Me crenlato"ll real Mal Me remains be assured! Into a suitable
conlainar barare it accepts thw remains. The opening of a conaimer or Me marefer or removal of remains will they
conducted betas a woman and will he done in privacy, wise dignity and reseed.
IDENTIFICATION OF DECEASED ,,,/
Name at Deceeaed: ¢� OF_7yct i4RT3? MerlMlSw. { /AOIL
WiKnown Addrsa:�_p CV�NIJT— L�De�NSl�it/y .6�8/
Place of Death
Sax: C41,11 OF Agar DOB: DeeofDeath Evanwtsd va ght
[Description of W9keVWntslll/ac�iin wfikA rases MR WdeIssued: \\
Yf/WL.Lunv� L.FJ.O i#vu1r / PLO L1u6LAtm )
PERSON IN CONTROL OF DISPOSITION
Omi m d In tmhd ddiapupion, jalgi ONE ores bMwugJ
I ant We am the designated agent of the discussed! tlesignarod in a WU or written instrument execrated
Pursuant W Public Health Law sermon 4201.
-DR-
Vl o revs IW knowledge MatiM deeaeese exacuad a wnuen end
W Publk HeaMI Law
n 42o1 ore will conaimiq airemian. ra Me ai.pwulon ornaalmr ref, Na aro (CMwnuMreMpme)
ski SOte/ ��a„s( Mm/9
ws�evu+ m...omai a da Pre+ z
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