McCormick, Vernon PINe V'ew Cemetery 4 CE0MatOrl UID
Quaker Road
Queens bury, NY 12804
(510) 745-4477 or (510) 745-4470
FUNERALHOME:
_.. RETURN Time:
DATE 8 TIME -REMAINS ARRIVED y
ME:
AT CREMgT ---NAME OF FUNERAL DIRECTOR ORREGRISTERED
b
RESIOExT OELIVERINO REMAINS;
NAME:
TTPE OF CONTAINER --'- .CASE p 99D
PLACE OF DEATH: � ------IEEE _
--,fear .
_ —PLACED IN OLD; T OF REMAINS e CONTAINER-
PLACED _PLACED IN HOLD;
PLACED IN REFRIGERATION
DATE OF CREMATION
TIME STARTED:
... ._7 —�
PLACED IN RETORT; TIME COMPLETED:
�._ 7:,DD __MOVED: __ •/�.ac{nr'r�
RETORT so IN WHICH REMAINS WERB11CREMATED:
DETAILED REASON FOR DELAY IF
REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY.
NOTE:
cnemgilOry L045M - _
RE79 THE PERMANENT FILE DE THE CReMATORV
M 6be
NEW YORK wp.rbmm W sgm
S'TAI Division of omslWX aM[IEMES
OPMR111XIT. Cemeteries One CPmme,
ies SO Warrington perms.e
slowly NY 3231 Am
iveP rvio GISMAI6226
w.s.WSMW+
Authorization for Cremation and Disposition
MIS AUMOria m Farm must W aom~and NBma pnw b emery c1 remains for cmmm�.
Date:General 2020 19e
Number:_
Lremalory Name: Pire t/av CreltvlOry
Andrew, 21 (Aaker Read Ql bury, New York 12804
pM1yy. 518-7454411
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Camation is tamed Out by pi Pe remgm of'he daroeaed and the mnlelner IoWing me remains into a uemafwn disposal where
tM gresubjWedtoimnaeheMana%me. TheM1 taMNmswlll lrr it and Ceneume saeryNing ett boa aM maW,W Wdh are all NM we[Me kid after mmatlm.
Fdlwing mmatw the(Forma y we take reasonable aforh to normal all of the remains and other maknal horn the oemefpn
Chamber, but Some minimal dug and residue mil likely be gels behind. The vemMory kalumarele intldenlel and fweled mWwiial lam
talk remainswerse Inargial and Magi Mora l MII be disposed of as register bylaw T"vemMdremainswillWmechaninlN
pulver'Ized into small pious anal plead into a designated wMamerorurn, CmnaW mmaim PftmIly am PulVenmd until no
slrpk fragment Is racopnl ble AS ebIWI Use",
OPEN NOOF THE CO
Man(moral may only open the commin ur Indiana the on managed human remains In lamed uumoUnttl, suc%es to confirm the
Mtry of n remats mencemsed Or to el thest no material Is Summers Whisa Ins an Mohamed in 2 chiml lner whi ON is rim suitable for lcnmatlane ch as coCBfB1nd9 me
l e or mesathe ccm pan,Me ll
m2Wq will "ulm tha1Ms mmaina be moved Into a sulMOle wmete WfaeItacmpm the mewing. Thempen ofa
container orne"most gramoml anmam¢wlu W condoled beam S vage¢¢and will be done in prNaryr with dignM and Nape s
!�Fm
Name 0Dareased Vermn McConnell Mnietl
MeriMl SYmle
Lag"am Addres¢: 137 BluebYd Read FM Edward. New York 12M
Plea of Dean: Glens Falb Hsyrvtel Me park Go Glens Falls, New York 1=1
Bak: Me OF Atli Doe. 07-06-1943 Dare aoei W-01-2020 Eablrelee weiBnr 160
Naumann of mskauwmainer In welch affai ktn be dsliaered.
Florence Casket, Plywood Corrugated cardboard container.
PERSON N
XLONTTROL OF DIMPOSITION
(Porem(a)m mor OF"08Nn, i morONEOffm WOKONS)
MaRso that the designated e0eat Of IW d¢ SM denuma ed in a will or wiMn Instrument extrousel Imaging So Three
wtlM law swan Q01.
-OR--
iLJ Ave have as knmNedge Mat the Seasonal ease tided a w rmen ingtumem graming W Public Health g W bodies 0201 or a
AN mnhnVg dirahons br Me dislpgtlon of his or her remains and IMre are the persons) havmp pnonN under Publie Hei Lsw
Seam 4201 an !have the right to Supreme natural of remanc of Me automated. Mylour r onshto b the aeaand is as
fMlwn:
Vernon McCormick
COS1BgB f IRev.Oill Page l of
Authorization for Cremation and Disposition
(Inaertfiom lM1e M1af 6eb J
Number 2 Desc iptbn'. The surnewinOstaxam
3. Tpemmdesgnatedlnywi0rgpumuadld PUNicHe hL"Sxti=QOI(3);
swininng b. This euMrna domersshe"Whom
S.
S. Any SuNlrva9Deem, agrarian team W age a oNm:
5. 4mrspngu irg rather years of age or older',
5. A kwlully spurred!Familiar
t. Any Gar S)eigMgn team of We a older entitle] to share In the aside and WhO Want easel in elelionaliip to Oe deryaod:
I. A duly appointed theory of Me eahte:
9. A close Mend or relative who has executed a written statement pursuant b Public Heats Lau Setllm 0201HI;
10. Ach'ief Racal oFkerof a county m aPai adminictela aplxvnlee pursuant to the 5umgeld a Court Proceeye Act
102. Any either person who is acting on Whom M the diCamed and who has execued a wheel statement purni to Publk Hmm
Law Sseicn @ot(n.
(f a1i THREE many leNawMg)
✓r!� IMb hereby affirm Met the body Of We dNeased does net contain a betlary, battery park, PKI r radioactive Implant
or nakamare eevlce and that any such deal were remov Pe Orto Me pecuddon of this AUPW4adon Fort FWNe by awarded
t *IItems plor to Orientation may myp In hams to era onmatrry And cnmsbry perFOnnal.
1 9 At affirm tat'restructure have been limn to Claim C.mai
epaNinO the removal Of any pelmet propeM or Other thing 01 value which any perem siming beWu w any family member Mane
dectiasel washes to Fireman Pine Visa Cre mtl
a6 na reeponelble for the mmWal as persuaded uema Wan the Wntairaer admantheremains MthedeaaM personalhemslashmIts
container orphan Me mmelne will be deaboyed q We cmnabm wescnd and mrrnotbd rWkved of ercematiore
I My IIWO hereby mModu P're VIM Cematory
w
m mmm M. remalm ornm ded..ae.
(tMaM OPnoNAy
lead heeby attempts Me named eumret eim=rto Provide for Belli to and dfomation by an alternate
,eared.of.(drub MO necafterni cmny�ory a oaddide of ueh reml director,and m emend Was farm b provide Me coffers command
FINAL DISPOSITION
Tinmeanaultnhed to rearm,the uemeted rgnalm M the degV Wm Me aemlory Is.
Name. M. B. Kilmer Funi Home
Address; 135 Maio Sl. Saulh Glens Fells, Near Yet 1a03 pPme, 51&74"115
The cannot reran ,M deceaea will be Wandered m as matte:
Mmal Sor aNamnel Camara,
If M any ream the peson named above Min net 4ke posseaekn M the control rents ns,
Pine vim Crermhry
rdm+n t is suMeWmd to give possession Of
Me moraine t0 M. B. War Flicapprad Home
in pemm or by mgabred mail. Vu.wwmra..w
VBmOn MCCwm',k
DOS1590J(Rev. M W ntiww
Pnee3d3
Authorization for Cremation and Disposition
dagia,Me reassa )
.5 INJs understand Mal If Me remain are not entered Nicole lap bye of maretlpt
Pine V'mu Crematory
an immewmas Mai such as by recording, ass,rcavuw may tlipwe of the monwns in
L
(ICI ONE dMe hWWg)
An um to be used as a camainer Its Me merged nmairs has been automated M1 an M. B. ghb r Funeral Xprc
and Is Merchant as sawls:
MNe understarq that MMe um is 1W mall to had Me mism memvted remains, an adUhmal ngld container my W Mend he derni
-OR-
An um is net no purNeasd 1Mg who afeNnd Mat IF no un is pummad or fa mAse amended
Pine Vim Cram"
mwacwes wNl Flaw Me merrWed remains in
a n01d temFOrary Wmainer her oNiuNy,
This AUMwhatlon Farm was gmvded by China C. KpwpXa
?wnyvewre wan evei at
M. B. Finn Funeral theme �
1 A Main St Soft Glen Falls, New York 13 nram,,,v 7m
w w
»] s signed by Me Nnml direcloras xitne99 t0 iM evedt'rm.
IAMI have meet a mnplend copy Of this AullmMzaton Farm.
The penonlvl iden4fiad below IYvw the persoms)In Cannot 11 dlepwpan,cones by signing this Authenticate Form. M@aael
W the assual and Wmpla s"of the informal copied In cols A;Mw ar Farm and vMModze(e)Me hosting ,
Siged Mls2 yya September 3020 Judy M�CormiG � ///.r'( w-SHNL•�
137 Bluabid ROW FM EdwaN, Now YomF 12038 �
rm+dmnnnw aY++ea
WITNESS:
Claire C. Noopke / iL KnI
o..rdMuamvw..l CiC
01IX11
ROOeribmin
Imay.wmr
LOS18984(Rw OU 0) Page 3 W 3