Prouty, Karen A. PINe Vlew Cemetery $ crematorium
Quaker Road
QUOe RSbury, NY 12804
(518) 745-4477 or (SIB) 745-4476
FUNERAL HOME: PAS
Lp
OATS R TIME REMAINS --- - RETURN TIMe
"-'-'NS ARRIVED AT CREMATORY: y11 PP
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS;
— --oar _A� op—Tv
NAME "'—- -
TYPE OF --/ CASE M
CONTAINER NIy-
PLACE OF DEATH
ESTIMATED WEIGHT OF REMAINS S CONTAINER
PLACED IN HOLD:
PLACED IN REFRIGERATION
DATE OF CREMATION; -_
Y11m
TIME STgRTEO: _ i ATi �.MEDD 111 PLACED IN RETORT:
_5vc�t1 - MOVED- -- - -
RETORT tl IN W RIC" REMAINS WERE CREMATED: _
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED
FROM TIME OF ACCEPTED DELIVERY: MORE THAN GO HOURS
NOTE.. THE Gn,MATf0 LOG SHALL RE RETAINED Rq IRA __ -_
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i N owoe ponfa cnEen uES
0TEWTOYORK Divisionof
°°P 5mmwamiORT° ° Cemeteries ^"W"An"i
ekPnreOre'.I51e1M6]M
Authorization for Cremation and Disposition
This Authnzatim Form must be completed aim signed prior to delivery ammaim bar cmme .
Data Og10812020 Number: 1017
Crematory Name Pine Vlew Crematory
Actual 21 Quaker Rd., Quadentragi NY 12e0A phone LU A4 -10
CRF MN 18 AN IRREVERSIBLE AND FINAL PROCESS.
Cremellm aceme !out by pladrg the renYlns W the dowas erg W container,holding the emeinsinfo a cremation imam wrws
May are Subjected to Intense heal and flame. The heal and flame will Accurate and consume everything except bone and metal,
which are all Tat will he tell S acmmtion.
Fdlowing Gemation, the crzm all take re onabkeXoda to remove all Come remains and mar maternal Ran the mematon
Chamber but some minimal dud aim hoodue wil likely he as behind. The crematory will separele Incidental and foreign malenal from
Me remains and thimcidenbl and foreign materiel will be removal of as required bylaw Theca matedremainswilbem "nlr'filly
Pulverized Into small penes and Mackay into a designated Container drum. Cremated remains generally am puwenzed untilrro
single fragment Is recogn"W as skalend blacks.
OPENING OF THE CONTAINER
The crematory may only Open the conemer holong tree uncrematel human remains in llmflm cbcumstances,such as mCa rfiml Me
w ily of the deweaed or to ensure Pat no materiel Is enclosed which migm inlure employees or damage the cremel pmpeTy. If
human remains are delivered In a container which is nice uitable far cAmtliOn such as Ceremonial or en"I Ceske,the
toq will require that the Remains be m before
moved into a suitable conlalr re it accepts the remains. The Cpismaors
wmmM ine,ame tmnsM or mmoval M remains will be ConduMd cemre a wtMss and wnl W done in privacy, with dignity and respM.
IOENMRCATION OF OECRISEO
Name of Deviased. Karen A. Prouty marital Stains: AAdcwed
last Known address, 37 Sodom Cross Rd., North Creek, NY 12853
Place of Death Glens Falls Hospital, 102 Park Styee , Glens Fella, NY 12801
Sex: 0M INF age TT DOB 0911 Date MDeeh: 09107R020 EeimN dladdi 160
Description of CeYevOMlamer in which remains MR be delivered.
New England Cremation-Deluxe Container
PERSON IN CONTROL OF OISPOS T ON
(Person(af In rembol M d6 sofmn, Initial ONE of M mW)
1 arvi are Me designated agent CI Me deceased designated In a will or argon instrument executed pursuam to Public
Heats law Section 4201,
--OOR-- p
Sit_ Me have no knowledge that Pe deRased executed a wntlen instrument pursuant to PUNIC Health Law Section 4201 or a
All Wnminirp directions for the disrysigon of his or her remains and 11"are the Mmen(s)having orbrry under PUNIC Health Law
Season 4201 end have Pe rent to authorize cremation M Pe remains of the deoaased Myour nreiomhip W Mw dx a$Gd is as
figured,
Karen A. Prouty
00E4e%f(Re, 0,4120) Page 1 of 3
Authorization for Cremation and Disposition
(Inepi rypm the Admebw)
NMMi3 Catimn on'.SUNIVIrla Child
1. A person MAgml writing purial to Public Heats Wx Setlicn/201
2 The surviNnq apou
Mo. The wrvivine do se is penrer
3. Any surviNng child eighteen years of age or older
0. AWrvlving parent,
S. Asural abbig egheen years Wage an older'
S. A beside appointed guardia¢
B. Atluly pPuthlMgteen "amlof of age or
older ended W sham in the estate and who iLere creep in rebbanehip to the tlecesead
9. Adose friend or Abenve who has exmui a wnMn atalembi Pursuant to Public Heats Law Section 0201y),
10. AdrefFull officer of a county or a public administrator apmided pursuanl to Me Surmgeh'S Court Procedure Aql
t0a. My other person who IS actin on behalf of the dmemwd1 and who has eseCNed 8 small atalemend purchanl to Public Health
Lax merman 41
(Imfial ALL THREE acre rdbwing)
yJ( Ilwe hereby affirm that the body d the damaged does net amain a pantry, Wftl pack, power cell, radioactive lmplem,
d radmeadv¢tlevice and that any such andamis were remwM prior to the execution of this Authorlaacon Form. Failurebnmove
these hems prior W CnmWon may result In harm to cu CMMa and CMaWrypnonrml.
_IAws affirm that interactions have been given W David Alexander
r Masi
regarding the removal of any peecrel pmpeM mother thin W value which any personsieeng below or any family member after
deceased wishes to pMmi Pine V'lew Crematory
�Avl
is not reasonibk for the carll of personal Teems from the consairer or from the remains of me deceased. Pam IiNmslMlnma
ontafner«xtth the remelts sell be deaboyed batty,cremation process and mnnotbe retrieved aaercmmabm.
E lease hereby authorlu Pine View Crematory
"re"a weu
to cre the remains af arks,W msW.
(lnlll¢I OPTIONAL)
Iles hereby aothori a the named funeral dead«to provide for delivery to and cromacon bas an alternate
ammtlors,ddm In Me eaed necessary opinion of the funeral director, and to amend ThusThusm W pro forvide Me earned name and
ddress Ol Such alWmate crematory.
FINAL OISPOSMON
The person authorized A resave the mumaWd remains of the deceased M1om the Me WM,S:
Name:Alexander-Baker Funeral Home, Cal Alexander
Aderev: 3W9 Main Street, Walrenstaur9, NY 12W5 Pnorm: (518) 623-2M5
The ce kd remains IS damaged will be diepmtd of as folloxa:
Return to family
If for any reason the peson named above days not lake possession of Me cremated remaiie.
Pine View Crematory Is aummiaed to Who powesbend
x
Me remains l0 Alexander-Baker Funeral Home by ddlvery
nw.amrymkso
in person or by regiS mail. Karen A. Prouty
Di loserif(Rau. 041 Page 2 of 3
Authorization for Cremation and Disposition
�nn. e)
r��+,p day hask
—`LINsb uMeddi Mat dlna remains are W Clelnre]xibin 120 days or turn on,
Pine Vbw Caroni may duyse of Me emais in
an inNnemble manner, sub as by stseenrp. wo..aan
CRESUTNIN CONTR NERAMN
fin PIaI ONE MMa hiWwon)
Alexander-Baker Funeral
An um to the wetl as a consumer fixr Me vemNeE remains has seen purOmound M1pm w.....e
and is tleecnbeo as rolli
room understood that it Me um is ba mail W hold the eMre Crenated remains, an a]didanaI rgi0 mnW'mv may be used be delivery,.
N3_Anum Ismayatpurtltaseed. IN undemWMthNdnoumismurc oro eMW pmOded
Pine View Crematory win Were Me cremated remains in
e door tempom ry mntainer W delivery
This Autlwrballon Form wY povorf]by David Alexander was eve[utad ar
Alexander-Baker Funeral Home
3W9 Main Street, Warrensburg, NY 12885
and is signed by Me Sri director as Mtress to its emondan wawa
IWe have receNed a complained Wpy of this AUMOliymMr Form
The penrntst IdarNOed balm Wam the marmots) In control W dbposltioo.area by Npnnd Mie AUMoneab'W Form ademi
to,Me accuracy and compWanNF M the inbmmdon Combined in MIS Auffi hNon Farm and arAMdaem)the foregoing.
Signed MIS o day of SePtemEer , g T
�Imo�y J. Prouty
25 Thornapple Drive Ganidevourt NY 1201
si
WITNESS:
David Alexander
ioo� 'wwvr
fRii
Karen A. Prouty
OCS1 d%t(Rev.0420) Paaa 3 of3