Cleveland, Anna May Pine View Cemetery & Crematorium
QCRker Roacl
Q COLORS bury, NV 12004
(518) 745-4477 or (510) 145-447s
FUNERAL IOME:
DATE S TIME REM
AIN$ ARRIVED AT COCMgTDgy:"POE OF FUNERAL OIg ECI'OR OR uE DELIVERING
GR1
S{ERFD RESIDENT p -1P1
EMAINS.
NAME: _ .-. ANMA . CLE1AyHMD -. ._..__._
TYPE OF CONTAINER ---_._--- CASE R
-. . Fl RrI. fv n
YY.I
PLACELI
OF DEATH: II2 51, -._.....
ESTIMATED WEIO" OF REMAINS A CONTAINER "
PLACED IN HOLD:
PLACED IN REegIGERpT ON. --'- _
DATE OF CREMATION. ---
NEMATION Z
TIME STARTED: - _
ME PLACED IN RETORT
--""� I • I'L. . __MOVED
DETORTD IN WHICH REMAINS WERE CREMATED
DETAILED C - HOURS
FROM
REASON AC FOR DELAY IEREMAINS WERE CREMATED MORE THAN AB HOURS
FROM TIME OF ACCEPTED DELIVERY
NOTE. THp
CREMAT40N LOG SHALL _ _. .
W Sue
NEW YORK I STATE OFDivision of OMIOOep OeNneMltlbTE RIMS
g
rub on,Cemm¢rze Pill,CemefeneS mnNP@z3100m
Ablinsy Ts" negdgAx 6Pg6
Authorization for Cremation and Disposition
This demodulate Form must be COMPMea and wit ed prior to,slivery of remains for managed.
only 09/17Y2020 Number'. /0
Controversy Name. Pine View Crembi
names'. 21 Quaker Rd , Queenebu NY 128W Proms
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation u camed Out by placing Me remain,of the Mohamed]and Me coMampr NOkrry the remains rmoa nemetion chamber whim
Meyamsubject,to,name Matandflame. The heatand flame all brokerage and og OF ereryMl, wall beareems!metal,
which an all Mal will be led after cremation.
Following Cremation, Me crematory will take reasonable agent to remove all of me remains am Other material from the xmcil
uembm.Me same minimal dust and residue will likely be per behind The OremaMry,will separate Irggemel and foreign melmial horn
Me remains and the iradental and foreign melaial will modhposed Of as requital bylaw The Gemaled remarM wall be machan loony
pulveriow into small perm and Decreased a designated container or um. Oremab r IMgenmllyarepu"mWur Ino
,item In a is ncognieabN ae skeletal tissue.
OPEN NG OF TXE CGXTA
TM crematory may containeran Open Me making the un founded human remains In limited circumsttances, such as confirm Me
gmtoy INihe decreased aria ensure Mat no materal is enclosed which might Injure employees or damage Me uemmorypgerty. lf
human remelts are dellvarytl in a container which IS not suitable for crxnation such" samurai or mlM1l WhN,Me
,mannallork,will require Met the remain. be movW into a suitable suddenly sabre It accepts Me r ins. Thecpenin afe
container crime translator removed Of remains will do conducted before a wryness aM will be done in privacy,with dignity and expect.
IDENTIFICATION OF pE�Fe
Name of Damping: Anna May Cleveland MWeI SMle. wltlOWed
Last Knower Allowed 2" 13th Lake Road, North River, NY 12856
Plain 0f Death. Eldelwo0d at North Creek, 112 Ski BOW Rtl., North Creek, NY 12853
Sex. ❑M ® F Age: 79 We, 111"1940 Dal of Death 09/172020 Estimated waght'. 150
cestrption of WkWmm finer in ii remains will be radial
Florence Casket-Deluxe Container
PEnBMINCON OL OF DISPOSITION
(Persm(a)in o'.nVd W disco4fbn, g/(r@IONENMe hlMwnB)
klea—m � I shared am the pro t ed agent Olderdxeased designated in vast orwlNen instrument election pursuant o Public
Section 4201,
+M
/' IrlNe move no knowledge that the delawetl executed a whom instrument pleasant to Public Heats Lew Sooner 4201 or
will concerning directions Far the msposkon M his 0r her remain,and may are the pemards)having Phohly under F emic Heafth Law
Seceona201 and harome Whttoauthonzecre tOnOflheremainsof Medereased Myl urmwtlorymlpw Medeceasedbas
follows'.
Anna May Cleveland!
D06-189611Reu Oa20) Palki
Authorization for Cremation and Disposition
nnsed=in me rut arrow)
Number Discraden. SurirvinO CAItl
3. T�R 'person in wr'Nng pursuant to Public Head,Law Section<301(3)',
y spou
ad menursing demand partner
a. asurvnomg and elemom years of was or older
S. Asumi BPedinl',
summing sibling¢queen years Of age or older
S. A4wlully apatimeal
c Amp (s)eighteen yers
may or older written to sham it the eatsly and wno lyare cloaesmrNanonsn p to u a 0eceax wal
dC A duty
appointed wu lamofthoseniorg. A pose hand Or hwuoa (mendNed i Wrsuant to Public 3ection0o10. i l officer a county or epubi phericl8PW sx Surrag sSCe Pedn has. My Other Person who is acting On beneMOfMe dxcamed and arm, has executedawell stmemantWummare to Public need Secure :
0001pJ.
GALL RIREE Oftlre modest
)7C Anne hereby affirm the Me baby of the dettabo does not counts n a barely battery peG, poser all dednegNr implant
Or rediramove divides and that any sou madmetr were reeased prior to the execution Arms Autl OzaWn For Failuntoramove
Measurement prbrtocremNon may mull in Mrm to Me mmvbry eM crmutay Wmormel.
ThC Inveemrmmalmin tionsh2veb ngirxnto Davitl Alexander
wwri
regarding the removal of any prsonvl Propamy Or oMer Ming of value Mint arty pemn bignirq below or any tarty member MtM
deuaeed winesm We we Pine Vier Crematory
s not responsible tonne removal eparsonm items horn Pe wnuinerw from the mmams of deyaeed. POe aIlameleainme
can Money or with Pe headline will ba debboyM by tab crmatlon promises and wnnN be mlrv" Hier mmatbrt.
1AL IHM1xmbyamhodu Pine View Crematory
M WcmmH the remlm Of
(labia(OPTIONAL)
Ilex M1mby authorize the named runenl director to provide her aHivary to and cmmvaon by an aMemab
overhaul ff
address of such devoted
atee;ury in m e opinion of the founded director vm, and to ind thism to ios provide me comct name and
OftFINAL DISPOSITION
The person Suftnud to re r lve me vemma remains ofMe mvwd ed fmm Pe mmM"is
Name:Alexander-Baker Funeral Hone, David Alexander
marine:_ 3We Main Street Warrensburg, NY 12885 Phone: (518) 623-2065
Trans,vemtlea reme;adewmed will W mspoxd N my force.
Return to family
If fa May mein the M=n named above does not take pouuswn MMe mmle]remains,
Pine View Crematory
mew»re pemncdzedngive pwbeedrn of
the upward Alexander-Baker Funeral Home by delivery
in parson Or by registered mil. Anne May Cleveland
w
DM1 Irl(Rev.OM30) Pege 203
Authorization for Cremation and Disposition
ributhirma following)
f� C Me andemmm mat ifthe remains am nm mined shot 120 bloc ofomnamer
Pine UeamGematory may Waxen of the moraine In
an nmtrlevable manner, seem as by soldiering, eo.r n
9918 S CONTAINEIROURIN
nONhis used
of Me Abnormal
Ac- An um to his as a container or ma m eeated WhereWheni has When Aiexantlar-Baker Fvnenl
purchased mainA e
and is descried as moons MacKenzie UmNalult-Black
Ave undmeland that it the um i bo small A hold the entre cremated remains, an abohniml rigid mnleiner may to umd for delivery,
-pp
An um is Mt yet pytgmeect lMe understood that of no em 2 WrchaaM or Whereas Wombed
PineUewGwyn cm atog will Pram the cremated remains in
I dad temltt container for Ni
They AINwrUatlen Form was PrWi by David Alexander was erected at
Alaxantler-Baker Funeral Home
_ 38W Main Street Warrensburg NV 12M5
Who is signed by fee famml Wool as.amass to its eecmion «mow
Ate have received a wmPleted COPY of this Adhorlaatlon Form.
Theeppommrq idemifed bilox ishom the Wool in oo l of disposition,who by signing this AU otlntkn Farm, a ovs)
to ry and mmplN ins of Na Information maintained in that AurhomaNan Form and authoribmi theforegoing.
Signed Mle 17th dai September , 20 20
Terry L. Cleveland
33 Cemetery Road, NofM River NV 12MS
AbmFas:
David Alexander
ow�o•mwwm.l
1ip3A
Anna May Cleveland
Isewoe..w
005-181. NCO) Poge9of3