Cutter, Betty Fine View Cemetery g Crematorium
Quaker Road
QUeensburyl NY 12604
(518) ]qv-44]] or (518) 745-4476
FUNERgL XOME:
DATE B TIME REM _ "Y. RETURN TIME
AINS ARRIVED AT LReMgTOgT;NAME OF FUNERAL DIRECTOR OR ftEGR13{FRIG gE310ENT �Aj I
ft
- _..__ . __ r„4� p T KO PING REMAINS:
NAME. ^ -' - -.._ _.__—_'
TYPE OF CONTAINER /' _ - - CASE p p I
_..GON FEn� oI�
PLACE OF DEATH Zp 1'}YDd
Rr 1k�yFu sr _sn tN L,�yr Eku_"
- ._._.
ESTIMATED WEIG
PLACED IN HOLD:HT OF REMAINS 8 -CONTAINER
-
___
PLACED IN REFRIGERATION: _
DATE OF IB
CREMATION
X TIME STARTED; _ 0
—I-'1111 ME E
PLACED IN RETORT COM E .cE••vp�y�I
,�e.1p11�, A.rL.._..
RETORT OIN OFLg�y O. MOVED I 1
WXICN REMAINS WERE CREMATED:
DETAILED REASON FOR _.
IF REMAINS WERE CREMATEOS� •
FROM TIME OF ACCEPTED DELIVERY: MORE TH AN 9E HOUR3
NOTE. Die cREmgi ONL G --
Authorization for Cremation and Disposition manmm.araam.
saw Conners Pam, nanw�n w
umm.nytnn
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M6 Auamdaaeon from maatba dorNPfegad m si oMpd"m r2a h/ of comma Bar
namaaon.
Date: 1 ;6 ?0 Number 99J
Crematory Name: PIm V cre wen
mod ' Quaker Rmd, Quaenebury, New YOM s28o4 Mom, 51017451
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation is carried out by placing the remains of the demanded and the container holding the remains into a
cremation cbamberwbem they are subjected to intense hemand flame.Me bert add home NO Imimy and men me
ev hinge Oboree metal,which am all Mat will be kit after ce aflon.
Following cremation, the crematory will take reasonable InTom to remove an of the remains and other mate nal4om the
cremation chamber, but some minimal dust antl reed use will likely be kh behind The crematory will seWnte Incidental and
foreign material from the remains and the incidental and foreign material will be disposetl of as required by law.The
cremated remains well be mechanically pulverized into small peeve and placed into a desgnated container or urn.CrmaM
maim geremlly are Wu Htt Mall no Nngk ft p mt is recognizable as"k dssue.
OPENING OF CONTAINER
The crematory may only open the container bolding the uncremated human remains In the ided nrcummnces,such as to
cashrm the iaemM1y of the More and or to ensure that no mrtmal is roamed whim might inlure employees or damage
matory pmperty. If human remains we delivered In a container which is nm suable For vema such maa moniNm
MINI wskm,line cremmarywill require that the remaim be moved Into a suitable container before it accepts Lie r Nns. The
opening of a container or the transfer or removal of remains will be conducted before a witness and will be done in privacy,
with dignity and respect.
IDENTIFICATION OF DECEASED
Name of Oeceasetl'. RtTN C/ IRFR Mamel8labm rr1UnRcEll
Last Known pral IF W ST. F%]ll 711 FNC [gI IS NJ 12tDg
Place of Death LSpME,y for, PROVE)
sex OM tkF age: ^III/ Ma: Date of Death 20 Eatlmaled Weight. 1�n
Description of casket/wmai�rrer in which remains will be delhmred:
Comuaated Cardboard Box with Plywood 5tarmark Model a 38808
PERSON IN CONTROL OF DISPOSITION
(Perean(s)in mMml of disposition, initial ONE of the following)
I am/We are the designated agent of the deceased designated in a will or written instrument executed pursuant to Public
Health law section 4201
-OR-
I/We have no knowledge that the deceased executed a written Material pursuant to Public Health taw section 4201 or
a ill containing direction for the disposition of his or her remains and (Container! nest page)
cml�fI bar 01 nl wR rt , 1 w tad
w
I am/we are the cersonls) having priority,under Public Hearth Law section 4201 and have the right to authorize oemation
of the remains oft hedeceased. Islander relauomM1tpwtMeeFeaseC Is suitableness
lrwea from Me rrstxwwl
Number'. IDescription: CIESE UO hui 1C "TER
A person designaead in venting pursuant M Public Haddam Law secgwl I2o1 (3);
2. The surviving spouse;
2a.The surviving domestic partner',
J. Any aumving child eighteen years ofage or older,
4. A survivirgparent;
S. A sumving sbding eghe years cf age or odder',
B. Alewfullyappointedguardian,
OAny persons) eighteen years of age or older entitled to share in the estate and who users closest In
reationshi d to the dec ustal
B. Aduly appoivad fiduciary of the estate:
h. Adosefriendwreativ ohasexec WawM mead pursuantWPublic HaaMLaw§4201(]);
TD. Achatgsmio wrofacountyorapublicadministmWrappointed WmuaMto Me Bumogates Coud
ProrNure Act;
1Oa.Any abler person wild is axi on behaR of Me deceased and who has executed a wriXen staWnnM Mail
to Public HPSIM Law§4201(7).
liggag(LL MRFF ofthelolbwbP)
I/we hereby aflhm that the body,of the accessetl does not soared a battery, battery pack, lower cell,rzshommme
plant, or radioactive device and that any such materials were removed prior to the execution of the Authorization Form.
Failure
of iluIreI to remove tares Rams Prior to cremation ran result in harm to the crematory end
oematary persol.
fY 1`1 I/Wehereby IN ran that Instructions have been given to ax,ms ,mad fissm Ral@mat41 regardingthe
tf any Personal property or other thing of value which any person signing below or any family member of the document
wehes to preurve. reemxmrm ) Pine View CremMory is not respansibde for removal of personal
items from the container or fmm the remains of the dtteased. Personal items laid In the container or with,tM remains will he
destroyed by Ne admitten process ant anent he reblued agent cremation.
I/lye hereby suthwdu(vnrema,mel Plre View Ueinatory to Eremace Ma remains W
t eaasetl.
FlXALOISPoSNIOX
The Mason auamonzed W receive Me cremated remains of Me tha eaatl from Me crematory is'.
Name: Bahr Funeral Home Persona
Address: 11 Strait, Queenchoury New Yorks 12804 photo: (518)M14303
The smmads! remains of deceased will be d'sposed of as follows:
Relum to family to be decided
If far any reasM Me person named above does not Glue possession W the ERmMetl demand,
tominoarreoi.i Pine Yew CremaWrvis authanzed to give possession of Me remains to
purcwmme�wel Baker Funeral Home by delivery in person or W registered! mail.
R CH l'-IiFR
narrower-tlan,mryol xmegpnmM niezNz
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IM'e understand Mal tMe remains are tlIXAakried wiMin 120 days of crematgn.
! eel Pine Yev/ Cremehry may,answer of Me remains in an irretrievebb manner,
SUM as by Scattering.
CREMATION CONTAINERNRN
lnlnalONEgtMjolbwO al
An um to be used as a container for Me cremated remora has been purchased from Baker
Funeral Home and is described as follows:
IMa understand Mel ff Me um la Mo small W hod Me entire cremated remains, an additional rigid wntainer my the used
for delivery.
-OR-
um has let yet been purchased. IAlike understand Met If no um Is puchased or otherwise provided mm v,
/ P'ne VwwC will place to cremated remains in argil temporary
container for defiverr
This ANhwizatbn Form was provided by p.... sswa,wmel GUW Raflertvp101W
was eaeruted at lMwdmmemmtl Baker Funeral Home
M�++inemeemam_ ll Lahvete Street Oueensbun Ncx York 1230a end is sgned by Me furend director
as%mmess Wits execution.
MAp have received a wmpleted way of this AUMorstation Form.
Tire parsons) idendfnad below Ware Me person(s) M conbol Ofd'sposdo n, wb0 by sgMng this Autlerization
Form, armst(s) W Me accuracy and completeness of Ma MMnnabon contained in Mrs Authorizabon Form and
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