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Winney, Leslie L. PINe View Cemetery & Crematorium Quaker ROad Queensburyl 804 NY 12(518) 745-44]7 or 1518 ]45-4476 FUNERAL HOME: DATE B TIME RE MAINS - -'- _. RETURN TIME NAME OF F VNER4L DIRE""'V tU AT CREME TORY:CI'OR Oa Fe GRI$rEREO RESIDENT UJl�- SLIVERING REMAINS: D aq NAME TYPE OFCON FAIRER: J� --- CASE IF PLACE OF DEATH: ESTIMATED WEIGHT OF --REMAINS a CONTAINER PLACED IN HOLE PLACED IN qEf RIGERATION; DATE Or CREMATION: TIME STARTED- py. --- FLH U___ �0 �0 q1n G .__ . PLACED IN RETORT: _TIME COMPLETED. ' ._._._. . RETORT /I IN WHICH REMAINS WERE CREMATED , — '- .- .. .M1IOVED: 4L fq__ SO , : � 'T`ff�I�111 "DETAILED REASON FOR O SLAY Ic REMgIRS wEVE CREMATED MORE THAN FROM TIME Op ACCEPTED OFLIVERY. AN -- VD HOURS NOTEThe — ➢oN LOG SHALL Ac RITAHRO lv THE PE "AREv HE OF THE caeyvony ST TO YOR KNAF DIVISIOI O f M&ODN. OF MmEs�EwS OFF °" " " . Cemeteries w.ma.Awm T.I "inal7��,t Authorization for Cremation and Disposition This AUMo fflO Form must As complaba and signed PH"A aa0wry of remerno Am mmeon. Oaie&1840R0 NunEec_ 103I Cremztory No.,Pine Ywx CmwWum Address:Quaker Road, Oueenabury, W 128N plows: SK C•y CREMATION IS AN IRREWRSIBW AND FINAL PROCESS. Csmarion la carried outby owing are remain of Me aewa mood and Me contyner holding the remains into a mmatbl chamber Om that are implied toIntense heat and%me. no h"tala Mmawlll lncl"n also cwuums eveMarng •adept bone and me41, which are ell trust will be IM ear ca mium, Malawi corrosion An crematory or ski reasonable eaoN 4 remove all of the remains and other materiel Sam the cremation chamber. but sane minimal ads Oil HISM ill III be lea bahlnd.FuNar nla vematayall¢epees iryaanrslaMbRiOn malarial M1cm the amainI and the mcaes a eM md,n material im ee IlbyaM Mu rewi ra bed m The nsmemll rtm all" n Irctlunio single fra into amen pieces and plan S into a aesianaW am0merornm. cremated am.ma vnr.Ilv.a Pwwnna until no single fragment I¢reeuenlmble as ex.m.I u..pe. OPENING OF THE CONTAINER The crematory may only open the camemer wi lug the unaemateb human remains In Ilmiwe circumstances,sm,as to contain Ina cannlyol tee aewasad Onto ensure that no matenal Is encomed which Mesquite employees or damage me crematory mo aM, It human remains ere delivered Ina contain Mulch Is motluMbN farcremation such as ceremonial or real caskq the iminamory will require that as mmul be mova l Into a suitable cwtalnr before It accepts the nmal s The opamng rife conalnrortha tranelmea removal of remains MII ba¢nductM before a Mlnec¢and ON be done In gmucy withdig^i1yandrespech. IDENTIFICATION OF DECLARE New of Do aced:Leslie L banner Ma As $Wars Whim'" Leon Known AWreR;319 Bsadway, Fort Edward NY Inbut Piece of Down 319 Bwdy. Fan Edi NY 12M se.: OM © F Ari DOB.OW23/1954 Data of CeaM:0�1vZ0A Eatmatea wayn: 220 Description of camuNcommner In which rwrsma will be aaliverM. MAµfinvoi 0nynweliri ('Mt- r CwL4w1 4I x1 `b W MCONTRDL OF D SPOS T O AbrMbof of dfAlwhydn,wall ONEefMe fabvnng) Or ea tee downtrend agent o1 the dricami designee! In a ON orwn0en InsWment azewdd pursuant to Public Heath Levy Beccon 4201. -OR- Me have No knowage trial the dama¢ed executed o wi Instrument alumina to Public Health Law Section 4201 or II MbiMry abet(ns for the d wrime on of his a her remains am awe are 00 Mmdn(s)moving priority under Public health Law Sedldn 4201 and have Me nghl to 3UMON20 aematgn of Ina mmema of tee decoa¢ed. Myfl)w MCOonhlp to the decrease is as foln , Leslie L. Winney DOS 1898 1(Rev. 04cm) Page 1 of Authorization for Cremation and Disposition Omen tram the Ina parow) wu .3 Descnpwn: San A parson ae il9naleo see ing xing pubi to Pupuc Ream law ssctxn tl3):420 2. The mr,AK spcnae, L. IN aurrlviN domestic pannar; a3. Anyi suu„vin9Oaks whip en news Ofage or other, . g parent. 5. A SUN...9 Ali eighteen years of pe or older 0. AIWi Am"Ifed 9uaMian; ]. Any persenlal eighteen yeah a age or older entitled to share in Me Mde and MO Sears dread,nlatlanshlp to her demoted; 0. A duly appointed rIducary aline fatetel 9. A close blend or elative who has executed a wi statement PUMAW to Public Hoehn LawShccn 421 10. A chlet Mi Mhmr of a Nuber a public administered quicMtetl pumMM M 009unrgab'sC rt Prodedure Act INA Any Oler mryon who is acting on p9nyf of the demasM antl who has executed a when statement purtwnl b Pi III Law section 4201. I--1��� �ALL THREE N me Ashoi '�Me herby affirm We He body of Me deceased does not wnfam a betlorv. Loney pack, power did. radfimuc oimwai. orM,wdlw device and get any such makMX were removed poor a the executlm of We AUM MUM Form Failuretommuw these Items poor to erm4im my mull In berm to the cmmsbry and cmmtlory pemonnal, hi Me Action Ma11rmNM'Cna have been gone,he Meld N.Panels re9aNMg We e0mowd of any persaral emberty,or Mher Wish of came which any mown sharing Iwlwv an any family member of qe demamd wi to preserve. Pine View Cmmat ,m is notmapmi for the mmiUP Men 'mrsonal p.ma from Me mntamer or or mm tlte remains or M.d.aeame. Parmnal lame lm lr MO container or wnn Me mmtlns will be a1spay0a 4the cm mstt mmes a on p and cannot be mis "after ammnm s . aasi Maherbyauthonm Pere View Gmemnum mene" d to cmmM the remains of this dxamed. fui(pIOPTRANALI tRw✓ IM homey 9a111nrlso the fumed funeral director by poNae for III Wand mmaaon by an tlamnA ry, if deemed racasmry In the minim of funeral director, and to amend this hem a provide m9 corset name and address ar such alternate cmmMon. FINAL DMMSITloN Ter person authonicd m receive the aeremd remains of Me dsceama form Me crematory a: Name CAddon Fmi Home, Inc. Address m Main a Hudson rotor,NV IM39 Phoce. 518-747d2A9 The mamaud remains of demased war be dlmomd of a9 iolw.s: Rammed M Family If for any maser iM pe named aL'.a doer cot take m s9 of the c Nd ramai %ne V'bw Cmmeefium is a"M MMen p99ea(en of sal the remolds to Ceneen FUMN HMO. IN Mw by deNvery In Arson an by,mgiswred eras. Lease L.Vdnby Ws.teg&r(Fev.(41 memo Page 2 of Authorization for Cremation and Disposition �l�(J5al ln�e rarow;ng) QRyf_I/We uneeramam date Me ramalna an nW earned Whin 100 days of aemauon. Arm VwwCre lip ri Ylgge o/Me examines In an whan hie manner, such as by sufteri CREMATION CONTAINEN10.N hale ZONE c/IM fdNi An um to as mW as a container fw"nanwkd me ns has Ceen purcheaod"in and Ia daeuiEad as blows: IM14e uMersland that M Me war rt Me smell to had the mass Moral Answer,an additional raid Penniman may be uW M deM1xry. Ai Pn um k mt yet puMaei IWO understand Mat M ro am is puvivai or oMwnse provided Pine Visw Cnmatohum dill plem Ma mma ed anion in nravr a a died kpni npiner far delivery,m m Thla AUPoaaatlon Form was provided by verb K. Padsh wµ e4w40 at Carleton Funeral Nome, lnc. ~ l wylisw gi IiI algae. L N W h p1O •ww `vvod and is elpnee dylnaMremlairemor..wlmea.to da emo udnHarr �ft.m IM havemmivedacwnpbtedmpyof MIs AUModzaM ,Form. no "events) Mandiffed Eelox ahm Me prson(e) In control oldMposlgon,who lyslgnln8 this AUMwitalion Form, Xmas) to Me it and complaWasW the lMormallon contained In this AUMorhXM Form and authorizem)the loregolng. ^.a Ml.Sig _gy_day of qko .20 LID Rmad Wheat Ana l� `Nmci 130 Hatchery Road, GeMevwd,NY Intl SaI WITNESS: MaA K.Par1narm"ohmei IIT83 LwYe L names Irrwavi COS-18idinev. 04120) Probi