Vaughn, Cecile M. Pine View Cemetery & Crematorium
Quaker Road
Queenstery, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME:
' ----- -. RETURN TIME:
DATE E TIME REMAINS ARRIVED < --'" CREMATORY
NAME OF FUNERAL DIRECTOR OR RECRISTERED RESIDENT DELIVERING
REMAINS;
NAME:
- ---CSC _JqucpN CAEEP 481D-
TYPE OFCONTAINER
PLACE OF DEATH: IIS
ESYIMATED WEIGHT OF REMAINS 8 CONTAINER_ "
PLACED IN HOLD:
PLACED IN REFRIGERATION;
DATE OF CREMATION-
TIME STARTED:
MIMI
—Low-_.. TIME COMPLETED: _ ryry
PLACED IN RETORT: p ---1"�
RETORT 4 IN WHICH REMAINS WERE CREMATED;
-"- - II
FROM
OF
FOR DELAY IF REMAINS WERE CREMATED MORE THAN 46 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE THE CREMATION LOGSMALL BE RETAINED
He PERMANENT rR4 OFTRe cx[mnTogv
DeparCnm1o1 mud
NEW PORK pIVI510110f DrvISION OF NmMETSMES
SrATEOF ern Plw
°'Qmmm Cemeteries •°NnellAldoo,
Away, abig »a22d
Authorization for Cremation and Disposition
This Af Ammetlon Form must be complete and AIII prior o aelryery of remains mr cretrat
ate I (II to Number: IV
Crmrebry Name:Pine New OremtlMum
Address:Quaker Road, Outermost NY 128M Phor 1 Nli
CRENPTION K AN IRREVERSIBLE AND RN pROCESa.
CremMian is mated out by plating Me remains of Meal ate and Me Wmslne'MOing the remeim Inb a crcmalon chamber where
they ere sublecNtl b intense bar and fame. no heal add Mma will InclmM*end consume av hin except berm and msbl,
whlah ere all Met will by left May cremmom.
missal crammon, µe crematory will Mike reasonable etlorts to remove at of Me remains and other matetlal from the crema4on
amber, but some minimal du h add rum mu,fall Idely be left behind. The mmrtdy will sopsaw moidamM and baler mabNl%a
IM1e remains and µe intldenbl and foreign maledel wXl be d¢posed of as required by law. The vmN remers all be merhanlcially
pulverized Into show paces And Macy Into a designated conwimrd um. Cremabd renal,generally are pulwtlW what no
slnplehagmenl is ricignluble as skeNbl tissue.
OPENING OF THE COMP NER
The crematory may only often W n Me rnalner Yet the urvre dhuman remains in limited Gmumabrms, such AllA,M All nfirm the
identity of µe dwm sad or to enure Mat Ad maternal is maimed whits might inlurs an rmy"s,or damage ere runway prcp9Ty. If
human remains are delivered In a wnblmr which Is not module for cremation such as coremonwl or matt casket the
sib owN1 ream Ire that the remains be movatl IMo a so Marks
Malnar before It accedes the anal AN The enemy Ma
mnbne r the lranswr or removal of rumeis,All ba conducted before a Maass add wall be tlore l n privacy,with dignity add rmmcl.
RENT FICATON OF OECEASEO
Name of reveal Cache M.Vaughn mit status:W WwM
feel known Address:319 inumb Y.Fad Edward,m' 12829
Place of lumen,319 Bmedway.Fall Ebrand W IN20
sea ❑M IMF All Doe:C3/0911929 wyamomm:OMMI EsOmaud WepM: 1 IOLBS
Oe%riptlon ofceakN/mMNner In wM1m remans evil be deavered.
Matthews Cardboard Cremation Tray, Wood Bought CardhOard Top
PERHON IN COMROL OFRSPOSmON
(Poe (s)11 dints of ds{ nion,(gypl ONE Of me kNowarb
I andi&eµe childhood Agent 0Me deceased designated In a Wit or written Iim"menl executed bowery m Pubi
HMM Lew Badon 4201.
t
OR�
g model
M1eve no fail 00 demolition
µe decenatlumint;and havy amthismeMWauanlN Pubec Heelµ tew$eNolt G2gi me
will mnwindng nd bale fn Ne 10 authllon of his tion her ad the ree ends of are lees persona)hardy p Uonemy hider Public Heats Law
selolwsC2gt and lave µe d]M1y to authorize mmeyion ad the remains cl No deceaeeG. MylOm raullonshlpu µa deceased la u
follo
Cecile M. Vaughn
DO l89 fMay,Wit Page t of
Authorization for Cremation and Disposition
Number
umb M1gn nKH Desci f
NemINr: S Deaadpuad: oap9ntar
L A mmn M119111en In w Arp pursuant b PUNIC HMM Lax E lon<201(3)'.
2. The survi spans:
no The su ing Intel Counter
]. My surviving child eighteen years of age Or dJvi
<. Asha vin9 pal
5. Asurvving titling eghteen yens of age or odder,
a. A porous,appointed guardian:
]. Any parse ls)eighteen"areofagewdtla-entitled W ahem In the estate and who]Were deport In relationship to the EeadaWi
f. A duly apMinb]frducury of Me estate:
9. A pore friend Or relative who has assumed a wmens emenl Wrsumh W Public Health Lew Section 421
10. A chief Oust oNimr of a county or a pudic administrator appointed PC muant to Me SunMale a COW Prouredure AM
We. My Cover pawn wM is aping on behalf OF Me damaantl and who had sill a w n materri pursuant to Public Heats
Lax Second 4201(7).
( ALL THREE d the(Whowtng)
ANI Me hamby mall Hret the body Of the demased does rot mmeln a battery, HaN peck,powx cell,redloecuff" haptent,
or ratllomiNmdear. and this any such materials ware removed Pi to Me nxeCution of this AuMo don Form. Feltum to mmow
M_sm�iterna prior to cremafbn may result in hands to tl mmatmy and crematory pemonnst.
�AV Me aXlmr Mat In Moron,have been geed to MeM N.Pal
driw
reparding Me removal of am peraonst promM or oNn thing As value which any Amon sing below or any brolly member of the
demand vi b preserve. Piney Crematorium
is not mWomble fix Me Mall ofpamcnal mans,Man No Container or from the remains Of Me deceased. Pxarand Items las M be
[amine,mwM me remalne will bs dmboyW by the arematlon process and Cann be mrtmed after emmnlm.
M Vega harabyauMadm Pine Mew Lremafonum
in...um to cmmete um remains Of the demasad.
mameOPTITICkst
L!IMw hareby aWhorlm Ma named funeral dimcor m provide for Mllvary to and cremation by an albmats
anmstory, 0 dammed ne m ceary In the opinion of furm m me ral dlretl ,and to and this form wmp to pri Me name aM
ddress of each snemate CMMMOry.
FINAL DISPOSITION
The eraon au wi, dto e e the Wremains of Me de maeM Man P a a armt i9 ory .
Name CWaloo m w anm
Funeral Home. Inc.
Address.. 50 Maln St Hudson Fells, NY 128N Phone. 515-047<X3
The aemaledremama Or demaaM All be disposed of as falaxx'.
EaI Bund at FNsa Street Cemstery
M for any rerun its pension naI above does rot rake pOtlmaion of Me creme really,
Pere view Cmmamrium Is,"Malaef M give Werssskn W
M re remains to Carleton Fu lHare, Inovmmrem by mall
Andand .w mrw
In damn or by mglakred mall. I As.Va phn
Dos-Imsef fan'.thel pa Page 2 of
Authorization for Cremation and Disposition
l�M. wwrvl
Miss wdemorn met due mancrum are mtaaimra withr upmmcf Mmmsldn,
Finn vlmv crem=oum may chrome&Me manners In
an Henri narrow, such airy sulbnng. ryn.aosuryr
CREMATION COMAINE W ORN
(rabour ONE oftlre bptwrvl
An um or be used as container for tlw uxnebtl rumors has been puMeM from
and aW ccMnd as MMhs
Wee understand Met I he um is too anal to read Me MtlK mounted ttmain.an MltlMnal III contllmn"be used for E N.
-OFt-
mc An um braes War pure 6W. IAse untensmMlhat 11 no for de NM or summers provided
mmvbw Cmnmlanum WN pi Me cmamMad Haiti In
iniamaa.�tl
a Mid temporary mmelner or delivery.
This Auhordaflon Form wet prooded by i N PNN FuwMvmml war eaeNNd al
Chrh on Fri Name, Inc.
Ed form,SL Hudson Fees. NY 12839 rvuwwmnxeM
and 19 signed by Me Mandl dlreclsr as wtlmas W Inn(xecutbn.�
Arm hWB remNed a completed cost of Me AdMr4atlen Farm.
The mnonis)Identified below Islets Me grammes)In control of dppostilon,was,by sl9ning this AUhorlZ rn Farm.*Nays)
to for accuracy and completeness,of Me InfomuWn contained In this AuMerhetlon Form ant auModm)e)the integral".
VignW Mls 31 day of August p Zow ,(
in An
f,m..
WITNESS
��nn
pwnwmv.a�md
CxC1i M "'�2 ha.a
008-1898 tINea. NQM Pause 3 of