Montgomery, Helen M F''^e View Cemetery $ Cremato Kum
Quaker Road
Queeasburyl NV 12804
(518) 745-447) or (510) ]45-44]8
FUNERAL HOME: PAM
DATE B TIME REM - -- RETURN TIME:
41NS ARRIVEp AT CREMATORY. - �y�p�Y.-
NAME OF FUNERAL DIRECTOR OR RECRISTCRED RESIDENT DELI ERIN REMAINS:
NAME
TYPE OF CONTAINER rwrrsa��� -CAAEA
PLACE OF DEATH. Sal EI I'G[R k
A it
VLJ�_Jz131
i8fca
ESTIMATED We10HT OF REMAINS S CONTAINER
_
PLACED IN HOLD: � S/r_.-�
PLACED IN RCVRIG RATION - - -
DATE OF CREMATION: _ _ -- / --- �-
TIME STARTED: .__
EO:
PLACED IN RETORT: mI' {— T'ME COMeLET . _
—_._._._. I'.�I .r_\V._MOVED: .____.- 1�I epRn
RETORT I/ IN WHICH REMAINS WERE CREMATED:
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN FROM TIME OF ACCEPTED DELIVERY: HOURS
NOTE, THE CRoMATI0 ._ ... -. ..__
mim
Audrodmtionfor Cremation and Disposition o.rwmm.rr�n,>a, "'wader"
as ai:7:�:s
Me AOMorieaetr0 FomrmwyM eomPIea dWVWPr W delivery of remalw for cremation.
Date: ljsj1 Number. 1063
Crematory Nani Pine Mew Crematory
Address- Ouaker Road, Oueenabli New York 12804 Phme: 5181]45i4]7
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation
r out cremationding the remains
to
chambewM1ethey placing
are Intense heatind Rome.The MA also the remains of the deceased and the sentainer gamewill IIMnerNe n a
o su
everything ¢aPt Extra and me ,w u M
er which am all M pmn at will be left Am Wm end ranmo Fonowing cremation, the cremamry will is Ye reasonable effort$m remove an atthe remains and othn Mate da fro in the
carnmatron member but some mi name I dust and residue will Wary W I ban Ind.The crematory ri separate I adds must and
foreign material from the remains and the Yincidental and foreign material will ber disposed of as required Wow.The
cremated remains will be mechanically Pulverized into small pieces and placed into a designated container or urn.Ofemated
malt neamEN are pwvM=ed omg as Nngle haltering is Patentable as skd Date.
Do KING OFC WARNER
The crematory may only open the container holding the un-cremated human remains in limited circumstances,such as to
confirm the identity of deceased or to ensure that no material is enclosed whim might injure employees or damage
centenary property. N human remains are delivered In a wnGlnn whim Is not suitable for crematlon main as a maremorgal m
renGl casket,Me nematay,will fpuires that the remains be moved Into a suitable container before it accepts Me remains.The
opening of a container or the transfer or removal of remains will be conducted before a witness and will be done in privacy,
with dignity and respect.
IDENTIFICATION OF OECEASE1DI
Name of Deceaeed'. Hide 1�/O�f✓�n�1` - Marml Stebw: MMr a r4
tdat Known 1�Address: � �� l "� —Qir 42
Place of Death-. \o-k. �/allP r�tiiZl_CP Pis.-42 Sxm%M le Ny �Zs32
Sex: OM NF sae: $O Doe 12 Datam Da.n1: 3 Jn Fatimaled wdRN'. �_
Description of ceaket/com ainer in which remains will be delivered:
OntrutpormiCaregagrandB with PI wood5 rb 1i R38808
PERSON INCONTROLOFOISPOSRION
(Persel In wmml of disposition, Initial ONE&the following)
I am/We are the designated agent of the deceased designated in a will or written instrument executed pursuamto Public
HeahM1 law union 4201.
-0R-
I/We have no knowledge that the deceased executed a written instrument pursuant to Public Health law section 4201 or
o Il containing directions far the disposition of his or her remains and (Continued nest page)
aoevw..,law.most "TM"rq
I am/we are the parasols)having ancnty under Public Health Law se[Yonazol and have the r18MtowUotltt p ematbn
of the remains of Me deceaaed.My/wr continently to the channel paF faion,
IMxrthwn Me leraebw)
Numbec_�BeecriWcn: drnu+h+ r
A celson designated in writhing purnuMN to Publk Heamb Lawvgbn d201 (3);
2 The session Names:
The surviving domestic pamler,
Are/ surviving child eighteen years of age or older;
1. A surviving parent
S. Asurnvingablingeighteenyearsofageorolder;
S. A lawfullyaPWlnledguardian;
]. Any Persons) eighteen years of no or older entitled W share houseboat and wbo Nare closest in
relationship to the deceased;
B. A duly appointed fiduciary of the estate;
0. A close Marc! or roe "who has sxeWted a seaman statement WreuaMW Pudic Health Later§61o1(]);
10. A Chief fiscal ofilcar id a county ore W blip administrator eppointed Pursuant to the Surrogates Coud
Procedure Act,
IN.Any other person who is acting on behalf of Me deceased and who has executed a women statement pursuant
W Public Health law§4201(7).
finkllaALL]HRFE o/fhe jolbwlrpf
lj� I/We hereby Who"that the body M the deceased tices net contain abtery, battery pack, power call, redioaRive
plant,or adioactive device and that any such mates als were removed prior to the exertion of Mis Authorization Form.
Failure W remove these Items Puts to oematbn may result In span to the uemineyyrtl comow,personnel
5 I/We hereby affirm that instrucions have been given toµrc.Was,vm,^aeO Smrreoker_ pypy5�negardingthe
mblaval of any personal property or Other thing Mvalue which any Person signing below or any No fly member of the discussed
Wshes Mpreseve. laemmnnemel Pine Vim Crematory is not responsible for removal of personal
items from the container or from the remains of the&ceased. Personal item Mt tar the combiner or yeah M1e rtmpens M11 be
�dj(WFrrayed by the cremation protein antl short refound saber crenrespe,
il$detaased.less hereby auMMcelm^ear^a•u Pica V'e C to oemab two income
FlfUIbLSPMT
The person aNM1orized W receive Me cremated remains of they tlxeaand from the cremalory,is:
Name_ Bator Funeral Home Personnel
Address: 11 Lola t QuonsbuN. N ark128"
Phone: 5181 ]Bi-03 a
The cremated remains of deceased will be tlisposetl aaz fdlowa:
Realm to family M W decided
If for any reason the parson remed above done not take possession of Me cremated remains.
(ew.wwyrwnl Pins V' C 1 is audwmzed W give Ponspeon of the remains
rFwiumm=^vmel—Baktt Funeral Nom by delivery in tPosen
�oor by registered mail.
oosraw-ra len.pvml tf MM}aMt I
(mQpl metlmwlnvl
��{��� " uwe unaereosnd Mat if Me remelna are npbtlYned wimM 120 days M cremation,
lewselarl Pine View Cremarory may dwpose of Me remains in an inaMevade manner,
such as by scattering
CREMATIONCONTAINEFR RN
tlnif oNEof MemlawMgf
_An um M be reed as a container for Me cremated remains has been purtM1asetl from Baker
Funeral Home and Is describe] as Mases
Me understand that if the um is too small M had Me snore command! remains, an additional rigid wntainer may be used
fordelivery.
-OR-
Anum has not yet been purchased. M W understand Met it no um is tuitional or orrerwise prowled tawmai
t Pine V'xrx Cremarory will place me cremated remains In a ngid temporary
container for delivery.
This Authorization Form was provided by dw.,w&ww,w„d
was executed at mwrv.M nor./ Baker Fun aXome
M�awnwmnxot 1 fav b and is signed by Me furreral director
as witness bite execution.
[Me have received a completed copy of this AuManzation Form.
The p rror(sl idarflfled barrow feats Me parmn(s) in normal olWsposition, who by signing this AuMrnYefion
Fafm, adasf(a) to Me accuracy and wmithdaness afire information contained in this Authorization Form and
authodm(sl Me foregoing
519rwd Mk dayof m
rw.easm` r rr1 CaAe.Jer
assa
nth 94 ( '11 4 128' 32
mite- nr �. saww .
WITNCE`SS: I (/�/
�Ta cc I
Funeral Home Rea. 4101130
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