White, Jean Marie FP(He Vlew Cemetery 8 Cre Matorium
Quaker Road
queensbury, NV 12004
(518) 745-4477 or (510) 745-4476
FUNERAL NOM,;
RETURN TIME _GATE 8 TIME REMAINS ARRIVED AT CREMATORY:
5 _
NAME OF FUNERAL DIRECTOR OR REGRISTEREO RESIDENT OCLIVIO NO
_ 401)q T(y REMAINS:
NAME
UNinE _193 TYPE OF M /�--CASE p
CONTAINER:
_ � FIII _ -�
PLACE OF DEATH
ESTIMATED WEIGHT OF REMAINS 8 CONTAINER_
PLACED IN HOLD:
PLACED IN REFRIGERATION: _ .
DATE OF CREMATION: --
TIME STARTED:
- hT I' MT�G'I3��
TIME CO D. Z
PLACED IN RETORT 1,� '
MOVED '
RETORT I/ IN WHICH REMAINS WERE CREMATED, .2 � /
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MOygQ THAN dp H�ppRS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMAT,O OG SHALL-..._-._
OF RETAINEQ
x THE PERMANENT FILE Or YEE CREMATORY,
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Authorization for Cremation and Disposition
This AaMorheaon Form must tea completed and signed prior to call or eosins he cnmNan.
Dick, 091OD2020 Number 9Q3
ax^a Noe:Pine Veer Crameterium
Access:51 Quaker RDatl Oueenabury NY 12804 owns (518) 74 n
CRE1fiJrT1ON IS AN IRREVERSIBLE AND FIXAL PR° M.
Decrease a Oman out try placing the mnaim dgb Mnaead add MB W Na holdng tin remains into a pamBIIM Mercer xlne
tMy are social wamend heat and form The hart and Moe will Inclrronn one consume avoided goal bono end good,
whim am an that call I be left eror enm W an.
common cnmNlan, Me goal yell take reasonable of to ramo a all Mute remains and other normal"m Me crem=n
Mora , but came minimal dual aM residue will likely M kfl behind TheCramabry will¢perNeInadenralaMlotaign melanel Iran
the remenc and To inoidemm and foreign material Mu by disposed a as normal 4 law They aemabd nmi well M nedu It N
palKdZed into small pieces and plate lac a designated CamaiMr more, cnnytq nm.M.a.^enlN an purwNeed aMI ^a
siNWftgmentisr nlnbleaeskal g m
OPENING OF THE CONTAINER
The crematory may only open may whet her holding Me unaremekd human rxrein ,in limited prcumsraws, such as to MOM the
identity W Ne deceased orm ensure that re materiel Is matted which might mare employee or damage Me cnmmory pope- "
human remains are dellvared In s contalmrwhlch is net surable lorcM atlon such as wmmonkl at noel cans el ma
crenutory will npuin that ma nRNlns W moved Imo v auaabla conAinxblan X accaptl ma eosin. The gaming of e
wnrsiner or Ne 1rencM or removal W nmairrs will be wMUMd bebm a wiltnas end will b don in privary. wXh dg^M eM nepep.
IDENTIF"TION OF DECEASED
Name of Desumed; Jean Mark White wmelstehN: Widowed
Let Known comes;18 Chestnut Redge Road#1, Oueansbury , NY 12804
place of Deelh:Wesley Heal Care Center, Lawrence Street, Saratoga Springs, NY 12886
Sex: 13M ® F Aga; 93 DOB: U11611927 papeoll2sM; 09162/202g FsarWtl
Wunption of skegvny'rer in wfidt nmalnawlll Ce dd"rared p
e �4� S UC4 � ➢ Ce Y
PERSON IN CONTROL OF dSPO lI
(N5 $)M mrl ddiyualM1nv,Seem ONE or me b. 9)
merge am the designated agent 0 Na deRasan co mi�to a Mil or%then endorsed ebtukd"=am ta Fudtc
Me Sooner 4201.
.OR-
IAft have no damages trial the Managed"cac e a when internal punched wpudic Haanh Law lemon 4201 or
sell¢muttons directions for the discount of his an her wages aM lane an me anyway)hating prkatty under Public Heard Lew
S M42010mhave Ne NhttoammMea "onoltMmains&t dC yead. Wy ern fthlpmmadet SOaBs
blbx
Jean Marie White
amea
DOS1S9&1(Rw. M/20) Page 1 of 3
Authorization for Cremation and Disposition
(i a ff firm the lie bebwl
Number 3 Oasegtlm, D uehter
1. A person doesiOnakE In writlng punluM to Relic NeeNb Lew Simmons 420113);
2. The suMring issues,
2a. The suffving domestic partner
J. My eurvivin9 chile eghtem seem off pe or older
l A surviving Parent
F. A surecoing sibling eighteen mars of age or older
6. A ISMUIh app inted tardlen,
T. Any ttrsorms)eglMen years of age or older method to mare in pe¢Nets and woo iNre cement in Macnmip w MebceuN'.
3. A duty apronlM fidutiery M Me estate'
9. Adose Mend or Wb ewM has esec awritten etN tpursuant lc Pubs;Heats low SM'en e201(7);
10. Am let M lolficer of a counh or a public adminlmmor momindet purwanl to Me Sumgnates fowl Promtlure Act;
the. Any other person who is scfing on mMWff of this d as and who ions eseated a w n etebmeM Wnuand N Public Hotel
Law Sol 4201P).
THREE of Me klbwing)
Me Mreny aMrm that toe body 0 Me deceand duel not Protein a Wool battery pxL, power can. Rgosee eimgaM,
An ndlec hours arc Mat am suco mete6a6 were removed poor to the emotion of Me AUMorhe Fomr. Failure to mmwa
Maine Ness prior Up comalion may down In harm W Me mandatory and cx " peMrrMl.
IfNe elfirm Met MfWctionm nave bxneiven to W wnd M Burch
regarding My mmwN of am M del gusts or Minor Mlrq N pace which am permn Wnyq bcUw or my hardly member of Me
demam wimes to pre M Pine View Crematorium
Penney I
is rot temporal for the removal of peemal Items M1cm the onLLher or M1cm tlro remvns W Me deoxeM. Por ll M111ntle
somehow or earth to realm MII be desboyad by Me convention pm s and cannot b raNNvad affair cr on.
ALView Me authorize Pine View Crempatonnumn
m.wnwro maamafa Mmmvms altle aawrtl.
(ln#_eI OPTIONAL)
lNn hereby supreme the named Imdanl all as M provide for dalHery b ant cnv tiOn by an ahamate
consumers. Nd WManue ry in the opinion of tiefumral dlrador,and to¢mW Mls Men to prol Me corram name and
atoms aslash ml to cams l
FI LaISPOSMON
TNpMonmtMi to recalas Me OFMbd rMnaim WMe de homlM gemslgy Is'.
Name:Singleton Sullivan Potter Funeral Homa
Anderson: 407 flay Road Queenebury, NY 128M plum: (518) 7930d89
TheresealI ewaFM WII be diapmeEamrouowe'.
Realm tofamilyamily
Incr any reams the panel coned elwvedw not take pmsaeion of the min nmim.
Pine sli Crematorium 6awwbed W goes pm of
nget n
MaremienM Singleton Sn Sullivan Peter FutlemHmna I1yasNmy
M person or by dpieteded der Jean theme White
p lgglbf(Rev. 0M0) own Pane 2 of
Authoi for Cremation and Disposition
�rmnoweot
�V kJL�-�n^xrsmnaunnu�e r.meina ere ml ml^.e wa.r tmmysaaememn.
Pine View Crematorium mereboouanherennimm
m.saw+vn
an u n rtMeoe manner. such as by wining
CNEMNTNIN CONTPMENNNN
(lady ONEmmeftrYm )
An um to be used as a Wmander An me UMNbJ ensure Was Lean Wrthased M1Om
and b deccnMd As hollows'.
Idea uMv w nwt M Me um b on aura b MM mesYJn amubd remaim.Ad accurate rem rgmN MY as umd M wharry
LR-
�MumierotyelpoNaeed IfNe Wmbm tlutnro unYgecmeMaoNuwYe OroulmE
Pine Yew Crematorium Will qam the rammed remains ,,
a and Nmpo2ry container for delivery
This Auumilaeon Form was Croaked by Werth M. Bulich was ex«urea at
Singleton Sullivan Potler Funeral Home
40I Bay Ro . pueensbury, NY 128M
.waaww
and is si Wthe funeral director as wimees to in of«u4on.
Me here renewed a commHed woy of and Autlmdeetlw Form.
Tm wrecm4 fkanuned,,low Were the wrsoms)In conbcl of attenuation,whin M slanlrq MY Aendmen on Porm,mmi
or the accuracy ands condescend m tlx lmomutlon contained! In M4 Antiterrorism Form and suMatrial ths adrpmnd.
Slpned Mb 2nd dsym September in 20
Kim Filion
10 Re mareRosed. Queensi NY 1281 F
Ali
Weeps: I�
WerdY M. Bulich IA_ 0 A . Y
sueronmrarvrwvrrr
10461
Jean Mane White
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