Moore, Melissa P'ne View Cemetery 8. Crematorium
Quaker Road
Queensburyl NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: . .
---- _ _ RETURN TIME
DATE 8 TIME REMAINS ARRIVED AT CREMATORY: 5 - -
NAME OF FUNERAL HIM-ECTOP OR REGRISTEREO RESIDENT DELIVERING REMAINS
-_Tth MVP*(
NAME: _-. htff- ZA _ kWRt ._
--� f p .� ICYJ4
TYPE OF CONTAINER CASE F"t / D-I-. / �J '/ 1-
PLgce of DegrN
ESTIMATED WEIGHT OF REMAINS B CONTAINER
((g
PuceDm NDLD: 17W h fib
PLACED IN REFRIGERATION:
DATE OF CREMATION �-
____._ -- -
TIME STARTED: I
—"--- -- ----�LI'I �TiME COMPLETED-
PLACED IN RETORT: __ S�pM��'"'— h
RETORT N IN WHICH REMAINS WERE CREMATED:
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION SHALL OF - - I n PE x ixe PERMANENT FLL[ OF THE [nemAianr,
NEWT Division Ot Drv1sION OF NI've I'
STATEOi rams R
OPP0Ri0HT'- Cemeteries
Y 12231POOM
Teleran,
,.ls®IM6E6
emacki
Authorization for Cremation and Disposition
This Authoantlm Farm mualb completed and signed phone;delivery olremalne for verse n.
Dow.Sept 7, 2020 NUMINer /069
Cremamry Names PlneU Cmmabry
AWE. 21 Quaker Road, Queensberry, NY 12CA Phone 518-745Y77
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation Island aN W pwGy Me Ann Ins of Ms demand a nd the NMelner holding the remains Into a a hon CMmMr vlmm
hey are subjected m InwMa beet and Peme. The hx\and name will Incinerate and mmume everytMny aampl done and mabl,
which am all Wtwgl Ee lMaMr cmmadon.
Fallowing crammer,Marconi will take remessa y M MM remove all cline remains ant clear mawaal Man ale cremadan
mamma,, M Mine minimal dust and reswue will Arty be left behind. Theclammorywillseparawirc nwlandforeignmaw9l Item
the remains and Ra m akenwl and foreign matenm Ma Malspmed ores,.graved bylaw. The cremawa remmrs will be maMani[edy
pulvmieaa Innsmartpierceandpim InnamsigmwamnlaiMf0fum. Cmmawdmnalmganmltiampul"*aduaino
single mg menu.mcoanlmew ae akalml"Bue.
OPENING OF THE CONTAINER
The aemarry may only coal the container holding M9 un.MmarM Yemen mmair m Ir circumstances elan azmmltfilm ale
idemityol me Mohamed onto ensure Mat no maven d la anonym vAiJl III injure employees oraam]e Racremalwyprocemy. If
human Name"m delivered In a convener whim In not sulwdls for cMnanon such as mramonwl or make mai Me
crammry will require that Me ramalm Ile moved Into a suitable co einerdehm x acmpw Me remains. The cpnlry Me
lrwinerarme vanswror remoal of rename win m mnder'.wa tmfore awllrass aed will tea done m omen, wtM agniN era mmmt.
oENTIF CAT ON OF DECEASED
Nmnaof Demand: mliem Moore Maniel Simp'. Marred
Last Known Address. 4 Wflayoad Ave.. For ECxaN,NY 1282a
pwm M al ABhg el Ave., For Etlwand.NY 12VB
sex OM El eye.67 goal 6/4/1953 wtemmaM.MU020 EmratemN ht 110
Desugaon of mkeVmMNner In whet ramaim AN be,di lwle].
Minimum Cremation Casket, Florence Casket Co. Cardboad/Pine
PERSON IN CONTROL OFOSPOSRION
(Poram(a)in mltM N Msposlnon.7Dgyy ONE 0I Ma MVaetny)
a nn a am No designated agent of the demand dwgmW In a all or"ten iinstrument execuM pursuant m Public
NeeM tsar semen 4201.
-01o.
�� IArm have no knowledge Mm Mq mamas¢]exaorwd awrimum Instrument Wmuant to Pude Neath lava Section 4201 or
will contual dsedns for me mwposymn of his Or her remains ant Ind are no Poworts)having prowly under Public Hearn Lew
SBcdon 4201 and have the ngM to aucarlae memmm m era ramems of Memm WMurmlaaonsMpb MedateamdIeas
rollover
Melissa Moore
Dos-1896 ev.Mrzo) Pape 1 off
Authorization for Cremation and Disposition
(i xaim Me tier bees)
Number 2 [asmgan. The to^'"rre around
1. Apemn compression wart anal Publk lbaM tan 5x4an Q01(3):
8. The surviving sponm',
2a. The suMunq domestic partner
3. An,an We child Hgma of n years age or Leer,
a. AAdvance mmM
S. A survrvlrq sibling e9Maen years of ape or oeeer.
S. AIaMl"WoinW guardians
f. terry cannon(sl eight n want M age or recent entitled Ashore In the estate and who Were award in command W Me tlaSaed)
8. Aduly pO ,i fiduciary 0f Me estate
8. A area trend or Phone".has eaeNW a will sbbment pursuant to Pubs;Health IHw Se@On 4$01(7),
le. A&iet Haw olRer of a x M or a pudi"dmin,a r oppal Pursuant W tire SurtOgab'S Court PmWure AM
has. My ONm row n who is acting on aMlf of the dK see 6M who has eremree a woman statement purwant b Public Health
Lax wagon CC1(7)
()djg�)AALLL THREE of Me M,Mrp)
114 IMb Mnby affirm NM me body of Na decaasa]does net crown a Oa" bMi coca Wxsr all, raeioxTrve Implant
or radioactive al and Nat any such f eal wen removed poor to the esawtlm ofpie AUMWiaagon Form. Folturstonmone
mesa
Items parlorto cr eon may result In harm to to crucial and aerosol pW rnMl.
all_IAYe affirm tMtinstruNons haw been given id Timothy Murphy
rryaNi no the removal of any spurned pmp or enter tin M value whips any pamntsigning babes a any Ham tly memi of Has
dereasal wanes to pre m Pine NSW Counsel
is not resounsibk For the mmi of Me al items it=Me Carol or kpn Na comma of the demased. Pamnal Items"In the
container or MN Na remains MII tea des"e by m go Me cmyHon ant cans be ra4Nved alter MmaYen.
.�in Me MMby sutham, Pine Vex Cmmebry
R mr 4
to eliminate Ma remains of the dacwaad.
(I�IOorm(C) y
Haw hereby apparatus Me named Nneral dimmer to anvlW ter celery At and crenm4ae by an alternate
adma, eem ry� N ded necowN In Me opinion of Me funeral Normal,,and to amend Has form W pmvlca Me coma name and
dMs W each.dame,Mmabry.
FINAL WSPOSITION
The peace aaMom d to rgiw May aamaM ramaore of the decant HAM Va Model is
Name: M B. Kilmer FUMRI HqM
Mitsui 83 Broader Fad Edw M. NY 12828 prom , 518.147.9368
The aamrod remains Ol Mt W wN the ebpceae of m falbwa
a
Rsaop 'N fYVhiM,
If far am rMaon dK pareon named eboW coma M wo samurai cote cremated romans,
PiMNaw CRmamry A auMmtae]to And Itoaaasion N
,a,melne reM.B. Murder Fu lHdM F+mv�rvmi by defiwrY
in pan or by rpoMM mail x Mena Mcwe
C0S188&f may, Carl arw Page 2 of
Authorization for Cremation and Disposition
fAaalmewhei
1// Wub undemUM McOl the remain are not miner within 120,181 acRm .
Piney Chantey may dVy09a MV9 remain In
ftawd(wr,,h
an inavlevama manner inch as by ecatlann9.
CREMATION COITAINERNRN
(rstle ( NE&ffwmWewwd
As an b ire W¢a as a ronlainer her the Manse remains has been WrNetld"M
and is reversed as ycuon
IAge understand maul it me um Y Im what u ro Food the andire namabd remain¢, an well No!anlaim may W used her wlivery.
oR-
BCLAn nm 'u rM ratWFF09w. lA unaantendmatdnoumapuryneenarmMn pmldW
Plnevlaw cramymy an Maw Ina marri remains in
a said l rei wntemer W Mwary.
This AmendmeNon Fdrmw ryeaded thy nmo Murphy was submit el
M B. Meet Funeral Home
82 BmaM'ay, Fad Edmi NY 12M Irm+rvmxme
ne�r.
ends aging!4 Me beset another as wiplese to me eseeWgn
WJa hewn re¢hred a wmpi copy of this Assessment t Form.
The persunta)tanned below Iyen Me panoMs)In control of disposition,who by signing His AUNor4atlm Form,admitlel
to the accuracy and eomplebni of the Information container in the AutMrhatlon Form antl authortNq the foregoing.
Signed His PCM yy of August p 20
Poster Move
F&n
chi MhMi Aw., Fad Edwmd NY 12US
NTNESS:
Tmollry Mum Neer View,
ji
125n'
MNesa Means
nw.we_e
O08-0898JlRay. O442o) Paill