Piques, David Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4478
FUNERALHOME;
DATE 8 TIMER CREMATORY
-- RETURN TIME:
REAL DIREAINS CTOR
AT CREMgTORy:
NAME OF FUNERAL DIRECTOR OR REGTEREO RESIDENT DELIVERING REMAINS
_. _._._.._. _RK/QMv. RISRIS Ns:
NAME: AHDr� din
TYPE OF CONTAINER. CASE IT
�
PLACE OF DEATH;
ESTIMATED WEIGHT OF REMAINS 8 CONTAINER
PLACED IN NOLO:
PLACED IN REFRIGERATION:
DATE OF CREMATION:
TIME ST - ' 0 ARTEO. _ 34 �1
"— n TIME COM V LETED:
PLACED IN RETORT; )
p
...._MOVED: __..2 zp�Yffo-K Ij"rill
RETORT X IN WHIGH REMAINS WERE CREMATED: __ _ Mrs,, l
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED THAN
FROM TIME OF ACCEPTED DELIVERY: VS HOURS
NOTE THE CREMATION O
L e RETAINED THE PENMAN, FILE Or THE CREMATORY.
-EWYORK Division of Do"""'"'"��""STAI DNISN)NOFCEMETERIEE
OPPoRTUNnY. Cemeteries
Takwokins Pta1 226
Authorization for Cremation and Disposition voidol
This AUUprzatl FORT must ne aamPle end alpmd All W&R Wair malro for eMMWn.
Data. 051muo nmbm:_ 989
cmmatwy Name: vMe vrswcmmatay
Adereas. 21 Quaker Road.oLeen q.NY t39CC phone. (sle) Tell
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation ocared cut by plaurq the remains&SAY aem and the uxllairpr bound He human;Into a chermon chamber where
they are s edeclb b incense lsa m Pate. The heat and Name sea I Gnerne and Consume avewl lr except ben.and maul,
whim are All seat will He left after cmmmon.
Fcnewing common.Me crematory All mine nosonableeXOrb to remcue all of" remains and ottrer maternal "in me vematon
chamber,To some minii dust and residue will likely be let EehiM, TMcremepry µIll sepered inuaenrelaM breign maknel him
the remars ma Me ins abed and for madrel will be dlspmed Of As rnahmd by law. The vematpt remains MII be m6namically
pul,enzed OR
tlnpNIragme tW wall ncopnl Corona And ppassedsMlWl Ito treated Ameinmorum Crs nmelmpsmnllyanpu"N dun ino
PEH NG OF ME CONTAINER
The crematory may only oPo"Me container bolding MB unaema human nations In limited urcumstancow such as to confirm Uri
iconMyclMB aewased orto ensure that no mahmal O endOse]which migMmlureemoo s Ordamage be uemalch,pmpery. N
human mmina are dellwrml in a coMamarwhlm tan suftbleforcwmmon such ere ceremonial or rental cametsee
cimmati will rewlm Nxdw rsmnm be moan Into a suitable container Were Nemapm Me mmalm. The that old
eomm�ermrla tramlrmr remwm Crremmnswrn ce mnduclM befDe a w,Mwe.ana wkI ceacre In pM'aq, .dM mgMry ale upeM.
IDENTIFICATION OFFDECEASID
NAso&Wwased: Caefd Plmm. MaXtal$b1ue; Manbd
Last Nmwn Address: 335 J�. W 2, Sualoaa Splreps NV
Pkm Of t Santoge HwgW
sues,: Min 12r Age; 58 Dos. 04/24/1962 Case of Deem: Da2areDZD Eadmala vagm'. /Io0
DeunpEon OICK�heu-w(nlemar In which mmmm sun beWFrtma.
Crwl n C¢..7Ilp Cardboard Box whVooden Base
PE
(Poramnftoseem o/ ONE OF Me kbp )
I Assume are thedasign$W KeM of tie a%NM d¢agn r in a PAN o Instrument awesome Ru lb Public
ld Reach w Sec4cn 4201
INk have no kmoM]ge Mat Ma aemased e✓ecubd a wall Instrument pursuant b Public Health law SeNCn 4WI or
mining dlrectiom Car Me dlaposltlen of his or W remains and Inks are the pe weds)hap pncay,under Public NMM Lin'
sx 4Mt aN have Me neM to wthmrze cremation Of Me remains of the dewased. MyOur n nsNp b the doused Is As
k4bwA
David Piques
DOSI896ryRev. CLOD) Pps I of 3
Authorization for Cremation and Disposition
rrMert Mewaw
Number 2 LMscOptlan. care GDrMmBnPgaO(Spcucel
1. A msurvnl designated
aMaln writing pursuant W Pubis NqM law Section4$ot(9)',
L. rne¢urri eommi paMer.
1 Any¢univing NOW eighteen years er so an dit
A Asuir parent.
G. A wrviving adds eye n years of age an oft
F. A madly appinft gualtlian
7.
& u Annyprson(s)eg hmen years of age or older eni Ashare Int o estate aM"D Were di in radio ¢Ily to theyMmeyy;
y appointed fiduc h ry of me estate
S. A cline Many or ala4ve who hs� awntlen 9at&nem Purnuart to Public Ini b Mail 42010)
10. A Nel fil l officer of a county or a pudic aminietmta apposed WRuant to day Sunugea a Court Pw ure Aq
IN. Any dher piton who l¢actual on beheed of the demand end who Ma exe ftaw n maament pursuant W PUNIC Xedth 18W Sedlcn 41P01(]f
(l " pLL THREE of Me malowriph
In t by eMrre Mat May CMy M ble d Og dean not cmam a NX battery pad,, poorer mu, radSxcfiy mgant,
armdmenshe deNAand mMary such maWmis were rtmovp prior W Me execution Nine Aug aW Fos¢ FalWreWmn
if@"" ms pruor bycm am may mutt to 0nm IMe crematery and smeary Mmnmt.
6�)—IAYe affirm netlMNx sham Peen givens Rolland G. He"
dean frog the amount of any pampl prgerty or mail thirgalwfin When any Arson sltaln0 below or any famiy lrynber aft
Comae!wiatles a prawarver PON Yrew cmmaary
Is nNreapm¢Ide brtM removal olpmmel lama M1wn Na mnairlmwrrom lee min MM to demesed. Peaonal ryom¢MR In the
D La r MN Me aural IN will b daatl W by da cmmal proses add Penney bar alM Mar cm Aon.
hemtry adhoome Pine Yew Comaary
TV�L� m�®rww
by Premaa M. mmalM ot May amavew.
/�ovnorvau
(nn haMry muodm ue named runeal direcara provide bar clad Soend cmna0on by an aMmm
.edits.iffof uahbWnmesre yin a opinion a Ma heard diwWr,and to Samoan!MIS farm a provide Ma sorted mine arm
FINAL ouPOSIT GN
The peon mffi da Mail"Me fames] remaiM a Me eepesed Winn 0g aemdory is
Name comp opte FUre lCue
Addasa. 103 Made AH., 5aaaga Spini NY 12M pia. (5181'+0i-0S!<
The cremated smarts of demYed will m disposed of M Ml :
Realm To Fmiry
If AN any rsson the pion named Yps ends AN ohs pmep8gn aa Ma fNMbd remane,
Pine New camaory Ie ash 0 YM pDeseeaonIN
tla Mail to m.ry Cdnpanb FuR lC LIC by detiwry
In mracn w0l ragisared mail Dated Pglr
terial
GDS lO f(R mil n+meu
Ppe3a9
(,Authoorization for Cremation antl Disposition
m
urea alreNerane Nat If"remab9ere mbamm xmvn hmaewdwm,bon
PbNY Cremelnywy
Mnccnwsd maY 46pOb INNe rynaire in
en ilre4leeebb manrwe, euG e8 by acery,nnp.
SflEM1TIONCONTAME L
(Lre3@r ONEddre Mlom^91
—M UMW M Iqp as a a"aaw know vem,@p remym No Mean pvtlmead Ran
BM V MgtliNE ee Mbn'.
WAS ultlelBWW net HN,um 18 W v9ull W Had Me eeNnaem and W ayim, an sadv an o nEd container mry be ueeEbnCMNary
Mumb Myin Wnahmen lM unders2n4MelemumNW Aa,f]p6 msepnpwEal
Piea Yiew Crematory
rwwda'mi+rv� AND p'ene the npneb]emylN In
e now mmlvery weeny to delhrery,
The AaMwl+Mon Fmm wy pwW9y by flptl9eY O. Nap
__ wu emceMd
Cwnre9agnab Fumrel Cxe I w�a
,OR away Aw Senekg a 5pnn89 NYfRcefi
am IS sign ad by Ina Wrerel alretlw e9 wMea m a executo
WJS bore ma luN 6 cwnpkteE way o1 this AuNwhetlan Fonn.
The person(s)NanYSaJ below IWare Me"many)y)In eonbd d dlspceftom wino by slaying Has Aupor4MM Fwm,awaai
heMe accuracy am complemnea90 Me Imorm,Yon conmine l In Me AuMwhmbn Form and eulnortrelq tlm roreaolna.
Manuel Saw RMn day of Augu8t RO RO
Jam HaMIMer Palms
336 Jefferson Lot SerBLL9a Spends. NY
mmea.,m..m. yw
WITNESS:
Rolland O. Nap
svuuy�.0 awur w
11636
OWN Pause
OOSIMyyJ Roa. 0120) PypSdJ