Clute, Donna PINES Vlew Cemetery & Crematorium
Quaker Road
Queensbury, NV 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: CgAS)lSV#f Z_.- --
DATE a TIME REM ....___-'"". RETURN TIME:
REMAINS ARRIVED AT L2EMgTOgY:
NAME OF FUNERAL DIRECTOR OR REGRISTFRED RESIDE 1l` L NT DELIVERING REMAINS.
_
NAME. /ny ��� __ "---
- J7PLT+� kJTF� pp
-_. -. CASEH �ODP TYPE OF CONTAINER
�yR �_Cy /6 �_1JPJ
PLACE OF DEATH:
ESTIMATED WEIGHT OF REMAINS S CONTAINER
PLACED IN HOLD: F-/?� '-^�x
VLgCFO 1N REFRIGERATION:
DATE DF CREMATION -��
5 m
TIME srgrtrED: _ -'-'—
!�Pn ------._ _TME C M )(p
PLACED IN RETORT:
-
Pn
flE Z `YN }3m�
TORT Y 1ry WHICH MOVED
WERE CREMATED: _. _ Y`=Po• ��
DETAILED REASON FOR DELAY IF REMAINS W ERE CREMATED MORE THAN yg NDU q$FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE _ - __.E A i:o O SHALL HE nE M 0 x E PERMANENT
LE Of ix CxeMgiOAY.
ow
EWYORK D IbpeF CEMUERIES
Division of wI,IDB D. emar
Cemeteries
..�p�:righle se
wiviedmi
Authorization for Cremation and Disposition
To unobservant Form m get tea completed and signed prior by allvmy of remminstin emmmon.
DIANIQ O Nunbr. /009
Gema1M'Name' PIreNw Cremabry
Adger. 21 QU Rod Dutamlwry, BY 11804 n (51M Twit)]
CREMATION 15 AN laaEVERBIBLE AND FINAL P EN.
Climber is oemW But by p W go remalm 0 Me sew and ere wM wr K the mntlrs Into a:rem ga rw m
hey are wNed Miami nett and fame. The best and Mme well lnclxnb and enneume everything swept bona and motel,
wh Is h are all that will be Ma enter cmmatlan.
Fullowng mmAm Mp owakry vnl tab masonade efforts to remouedl Mtne remaine ale other material For ttw cremation
Ovemcer, but came mmlmal dust and h aaua will Ilkery by Ile behind. Tw mmatg mil separate thddenul and fnregn malmul bar
be remains and be Incldenlal and brags Mdwdxal evil be disposed em/caused by low. 11m animated remains will be nechanl®Ily
pulvenmdInto small pence;and paved Into a Reelfoot cantaimra um. CMMWdmmsinapanamilyampuM[ OWino
Ingkfmgment Is meopnlnblo as sbbbl flux,
OPENIM OF THE CONTAINSIR
The aemattry may only open the mmeiner holding the urraemakt human remains in timnMd nwmaUnax, such as W Wnfim be
identity of Me Overview of ensure Met an material M endowl vfiim might injure employees or dimaga tie a =,mypwdy N
human nmalna q delivered Ina wnolnarwhlch b ndaulbbla tin[romadon emir u<enmonlel or nnbl cxbf,Ma
ambientwill"Ulm the teasferorrefhe moval M'nM iim will be nto R suft�container cmdu Aware awMew nearby
sell M dd"oeIjn'sormalw TNowning We
pm'ary, s. ifigrany
IDSNTFCATION�eF �F_
Name of Dawawd: Dome ends Mamm
MCMaI Staffs
Lust Known Fdyeea 5r5sWn Rout 29, $neNZa SMMa. NY 12M
P"p of Devoth Serwtye Nmpbl
Sal'. ON ® F Aga. 59 we 05/11/1961 oewwam: 0aro0¢020 Faomabdvelm 7.Sp
Decmigni n of cwJvmonmnas ma/,whim 2mmne we be admitted
r+ . L�}j"ardbehj Box wlWooden Base
PCMMN
(GMM(s1Ns ordamioM,all ONE or Ism tieg)
WMANS are that dnigmtea agent of that demx dnigriwad In a will or whether Instrument exmMd puauaM as PWIk
HeaIM Lew Smivm 4201
-OR-
I KIMb hails m k owledge Mat Me den wI remains a w"Ilen IrebumeM Fuji W ord r NwIM Law'Section 4201 or
wIK wntaining direNons ter Me dissected of his orer mmwq and new are MapnonU) having preiriN under Pudic NeaIM Law
Sacfm 4201 and have Me Right W aWwrlae cremation of the remains Mthe dynessd. WMur relatlonsdp W tie aanaua M as
follows
Donna Clute
DOS IBM f(Re, 34120) Page l of
Authorization for Cremation and Disposition
Nrmder Numberom Me)sacrum)
. ' DewWbm Al.n cNm tspow)
1. AAlia sson a labod inwn0y Plural toPublic Heyde LAW Mecum 4M1(9);
2. g same
;
a. The surni eomntk Palmer,
B. Any surnmang Nile eighteen moo,wage or of
A Arural parent)
S. A survol setting egMean seen Of eye or alder.
S. Mars ly appointed guardian;
r. AM Pononls)eighteen yeM of NO a deer WhW W share in the Arms am"a Were G rearom relationship W Me eamesed',
B. A duly apmiml fqucuryaf Me sears',
8. A Close frets Or nlatiw top has mounted a w Miami pursuant to Public Heats Law SeNon@01(7),
10. A WN foal osmr of a county 0r a pul administrator apponsd Wrsuant W µs Sumgaa a CalmpmmMm Atli
1W. pry other fereentoo as thing on shhaH of Me eessell and cots has executed a wnMen sattmAnt pursuant to Public Heats
Law Mi 4201g)
rLi lAu nWEE a My WYcesym
IAw hereto storm that the Mindy of the esmawd Mrs rM carbon a battery WlsrY pain Manor Oil raeioµUva lmplariL
or ndQa tumor end tom end Man moral veers remoyd prbr a the armusin of Nis AWpeMUM Form. Failure W remove
N.e cams prior N eM ham madon may result In ha W Me cm Mry and cannery personnel.
/afN C fros Won Met reductions he"Men given m Iceland G. Hoag
regaling this removal OF any Minimal whoeTy,or other thing Wvmm"iN any mran alial del or my early member of may
facco M vnsMS M pmwrrx. Pins Yew Churl
n satreaconsibk for the removal Of personal Itcce man me mntairher or mµe remeMe aftlie eememe. Psnorul tome Nfl Inshe
InerorMp m me rowns sell dN II boyad 4 its cremation process and cannotq re Wabn r cmadere
c G We herein auµoriae Pine Vim Cremmory
m y mamnM Me emim of the d "OW.
(Mary OPTIONAL)
Vora Mnby aumatM µe named fuoaml director as pamlM for delivery M and mmmors by an aymas
mesry, Hdeemed necessary In µe opinlm Of Me fumral chamber,and to amend sale form to provide He comCt name and
aMd M such alarms rnmaary.
Fiel DISP eSITION
The Wn aumi W memory µs vematl nmeins&the deemed from ms monarchy a
Name: Commemorate Furc lCans
M ones: 402 M"Ave.Sate Spiigs, Nv 12M PM1on (ii'Metful
The amnaad remains coda ear alcold be cosAced of as lobster
If b may parent the pwemr saa dos rM MM paeanen of has remrm.
PM Yex CnsmMry
committee is eahvsee M give yepmeion of
she renaitma Gail M MNriwIC .. Irc yy�
Pessimisms,
iivery
n pram Or by nagamed mai Dnm om
DO 189be 1Na'. 1eal porvr Pose 2 of
Authoril for Cremation and Disposition
(MOMI df wmp)
He If undersell Met ff the remains are not Calmed whn 120 days 0 mdn.
Pre New CAmalo
an nreMevadM manm, ¢ued as dysreXenn9, i a
may Mail or the remair.e m
CREMAILIONCONTAINFandal
ddJiddOYEardmraaswrgd
_An um ad a ded as a poncho rar Me pmmHbd renalris M¢Min WrTaW finam
and i¢dese bed anmuows
Ii understand Mn (Me um Is= mail TO hand they Omar�abJ' amended,an Mtlbmel red aaaelver may Man and My dai
-am-
An um is and Tan dimensional. INJa unemand Met U ou um M paMeNd«otlervnse areal
Pma Vow Cmmelon will plate the gpnaW remmal
a reed temWrary nonlinear W dafiWry.
This Au zarkn Form way pmmMl 6y Ri G. Ndep was executed at
Cdnpes&Oavb FunerL Cam, Inch
A0 Maps Avar Saralo3a SpM ¢ NY 12W
entl i¢all 4 the Women director as Wt toi s execsiOn es
Ilk have may wild a cdnpleled Andy IN has AU Mzatl Farm.
The pmnls)maintained below Nsn Me Pomanls)in cp lof dYWsNlon,and by slpnlrq NY AUOprleatlM Farm,Nasds)
W Me accuracy and m mplateran oxeye IMarmathon caMtlned In MIS AUOwNaab'pn Form and auMcent May bnpoly.
Sgnad Mie Am daY a1 Sepmmonr 2020
Adrian CINe
MdS Ina R al 29. 6arads SWIy¢. NY Used
tai
rranwr«m ya„
WRNESS: ,J
RalleM G. 14Np
mwrmuwn wad
116M
Rnna GUY
WSI6g6r(RN• cal Ppe3IN9