Randall, James Howard Pine View Cemetery 8 Crematorium
QuAker Road
Queensburyl NY 12804
(518) 745-4477 or (51e) 745-4476
FUNERAL HOME: _ y,
DATE C TIME -RY RETURN TIME REMAINS gRgryGD AT CpemgTVRY: LL
NAME OF FUNERAL DIRECTOR OR Rl4RB{ERER RESIDENT DE- f1m C. RIMgIIIryS:
1'NS
_ _ - __ �
NAME: .._—
TYPE OF CONTAINER - -- EASE # 41Q
PEACE OF QEATH:
ESTIMATED WEIGHT
PLACED IN HOLD OF REMAINS G CONTAINER
_ I
: Ar..112L`(lY'
PLACED IN REFRIGERATION -- --'--- __
GATE OF CREMATION
TIME STARTEO:
PIACEOIN RETORT D COMPLETED! 1 .
73 : IrI MOVED (+ p/�
RFTORTNIN WFIICH BiO
REMAINS WERE CtEMATEO. AH B Ij'.'I 11/
DETAILED REASON FOR DELAY IF REMAINS WeDG CREMATED �4
FROM TIME OF ACCEPTED DELIVERY: MORE THAN q HOURS
NOTE: THE CRIMPY,N LO BE
New,York
Duke
NEWYORK Division of ONO MMM ERIM
STARDF DIVISION OF CEMETERIES
OPPoRIVNnY. Cemeteries 99 Whi crew,
story.NY 12231 (m
reasons GliessIC226
Authorization for Cremation and Disposition
Thai AUMwlaeWn Form must be Compbntl and signatl pnarto doi of Randall Mr mwmdon.
Dare- Septmter 16.2020 Number I630
Cro nalary Name Nne View Crematory
Address: 21 Quaker Read D bury, New York 12904 PWne Eb74E4471
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cranallon is earrgd out by iaang Me remains N Me de and!May comaiNr hdding Me remain into aoemacter clamber where
Veyeresubryledtointenseneatandtleme. TMMataftflamewill Incim t andconsumeew ingexceptbore@r ma .
which are all Mat will be NX after Cremadon.
Federal uemation,Me crematory will lake reasonable efforts A remove aN of the remains and other materiel from the cremation
Nam WIepeeminimaldustawlrevduewlll likdyMleft MMnd. The normal will separate Incidental and breign m9ledelhpn
the remains and the material and foreign meterul will be tl'uµi INas required bylaw The oemated remains will M meSaniraly
purder¢ed into smell piegs and placid Into a designated wmaiar or urn. CM 2af almpm llyampul"HwduMllno
single fragment he rewgnirable as skelNel Nuue.
OPENING OF THE CONTAINER
The crematory may only open the container holding the un-raWn d human remainsmlimped circumstances, Sun as be confirm the
country,M the de owed or to ensure that no material Is annual whin might Injure employees or damage the crematory prewrty. If
human remains are del ivartd In a come ther which Is not suitable for sexual such as oerema me or rental emm tlM
mrenal your rpuire Mat Me remains M moved I=a suitable coma.m balers iteccepat Me remaMa. The openg of a ia
Mainerm tMbansferw removal of remains fill be conducted before a Narrow and will he conem privxy, mi dreniNandrespect
IDENTIFICATION OF DECEASED
Name of Decal dames Howard! ReMell Manbl Status: Mal
Last Nnown Address, 1917 Cell St Mks lut ems, New York 1284e
Plxe of Death Glens Falls Hcknoral IM Park SL Glens Falls. New Ygk 12001
Sax: Is OF Age'. 82 Dos D6-26-1938 Data,Del 0915a020 Eatim.ree grit 200
Description of caskeVwnann er M when remain sell be dervered.
Florence Casket, plywood conugaled cardboard Container.
PERSON IN CONTROL OF D SFOSITION
(Pe dm(s)In rental Of @scintilla, Irtibel ONE of may btlove/g)
I eare the designs agent of the model designated in a will Cr wripen instrument executed resume to PUMIc
HetlM Law Sudon 0201.
OR-
INJe have no knowledge Mat the decmaW assumed a widen instrument pursuant to Public Health taw Session 4201 or a
11 turning concerns for IM disymbon of he w her remains and lake are Me penon(s) having Pooriry under Public Health Law
Soccon Q01 and huethedgNroauMna mOonoftMrmainsoftMdewawd. WMorrdallomhiplo Medew isas
Rosevear
James Howard Randall
DOS-1999-t tams, Mur Page 1 a
Authorization for Cremation and Disposition
pnmRlmm MelIlsf Meow)
Numba: g Dame ipll The humming spouse.
1. Apens=designated in eventing pursuant W Pudic H"M Lax Saipan t301 M;
2. The mrvMng spouse;
U. The surviving 0omeand panmer;
3. Mymrnving Hato eighteen years of age or meri
4. AwMvine parent:
0. A surviving sibling aighwarr years of spa or older.
S. A laMully appointed adveise
T. My Poreonm) eighteen years M age or older moved to share In Me move and Me mute dopiest in redion ship to Me bxemMi
B. A duty appointed fid coal the estate',
V. A core MMtl or relative who hasexecumd a"mn slalemam pursuant W Pudk meIth Law Section 4201pf:
10. AdeidMe officer M a =only Or a public administrator appointed pursain11a 1M Sumgate'a Court Promdure Aden
loss My other par who is adi no on behaN of the deceased and who nos prepared a woman Movement pursuant to Public Heats
Lax Seapn am ref.
fmna ALL THREE WMe mini
INJe hereby arm that the body M the Mode I' does not Wnlain a Hardy battery park power tall. 2dioeclive Impant.
and'pec4re dw'ta and that any such materials were removM Them the exemeen MMis AUMO =n From FaNummmn
Militia Items poor b cnmatlon may mull in harm to Me cnmMal and commonly puvonnN.
I(W affirm Mel inelructims have been given to Color L. emperor
regaining the rmroval of any personal property or other thing hevalue which arty Poll signing below or arty family member WMe
tlewawtl warms to preserve. Pine Yaw terminal
Www
is Mreapormiae Her Me removal of him oval items from me container mho= remains dome deemed. Pemomi Memo lei m Ma
/nUil «MM mmaine Milbedeaboyadby MecremationgrouseandwnmlMMri ahermmaean.
Ay I1We Mraby summer Pine Vier Crematory
rmani
to crenate Me remains of ma dacessed.
A afOPTIONAL)
awe her aNhodae Me named Amount director to provide her delivery to and cremation by an almmam
=entry, If deemed Model in the opinion of the Nnenl director, and to nand Mls boom to provide the coact name and
adds of such museum crematory.
FINALDISPOSITION
The pool gathered a mail Ile vernale] remains of the damaged horn Me UemaMry is:
Name: M. S. Kilmer Funnel Home
Address: 138 Main St. South Glens Fats, New YM 10803 per_ 518 745-1116
The=mated remains M d wul be Imposed M as Mims:
Burial Garr IT IT.Sg m SyMope NNUN Centel
If for my header the ceraon namW above does Per hike Momentum great mrreW remains.
End Vim Crematory is aunt«ae ro give Miami of
mender,xrm
the m"ins M. L. Kilmer Funeral Nome
b by delivery
inpmsah or by rrolslered man. a James) dRandall
OwerfimPW
005-law-f(Rev.oK[m Page 2 of
Authorization for Cremation and Disposition
n=aim.rarowirel
Me understand it the remalne ens W dairrcO within 120 days Of GemaeOn
Pine View Crematory
flnwnvvie"r may dNposeWline manner In
an imdri i manner, wT ea by Mowed
CREWPT CONTANER1.MN
( lONNEOI lolbMrg)
&An um to he used as a wMamer far Me aem added remains had been purcMaW form M. B. KiAmr Russians Home
and Is dea mi AS bllaaa;Florence Gratin Pine Um
INh understand that it the um Is this smell by Mk the aitNe vama@d mmeim,an Wditgnal III¢Maircr many be manner M delivery.
OR-
Mum Ismtynpwmaaed. Inveumer MthnPnCumiswrwdedcra emwpmwded
Pine View Cram" Meuo µill plate the cremated remainsn
a add temporary wmamer,tw daywery.
This AUftm tlM Farm was praulded by Gmm C. l(OrgpYe was erecWed at
M. B. minor Funeral Hama uarvuwrvez
IM Meln St South Glans Fells. New YoM 128M
and is Signed by Me 1MeRl monsoon as wiV98a 10 its Salvador.
INh have removed a compared mpy Of MIS AU~MUOn Fisher.
The"man(at Iderrti0ed bMux Islam Me perform)In Mntrd d diapwition,"a by signing MIS Authorization Farm,&l 93)
to the eGeureey, aMcanplWness a Me tnfammtlM carnelned In Min AuMamh M Form and sumarizes)the foregoing.
Signed MIS 16 day of September , 30 20 .
RIU Randall
r191T Call St. L6e Waeme, New York 12W f
Sense
Adhar
WITNESS;
Care C. Kcamom p ru
r n rmw Ram. w.s..r C F�
11932
Janet Howard Randall
lrwm�e
00S-18g8d(Rev M/M) Ppetd8