Burroughs, Heather Ann Fine Vlevv Cemetery $ Crematorium
Quaker Road
Queensbury, NV 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME:
._.__._-.... BgKfR
GATE S TIME - - --- RETURN TIME.
REMAINS
NS gRRryEO AT CrtEMpTORT:
NAME OF FUNERAL DIRECTOR OR REGRISTERE
r�GSFO RESIDENT DELIVERING REMAINS.
4 . �4ASAr NAME _ --ofAn[()
- IHLL- Bo��aIu� _ M
TYPE OF CONTAINER: 6 FFRP1 _CASEb
PLACE OF DEATH. FIi4Ll-EEU6�
ESTIMATED WEIGHT OF REMAINS S CONTAINER
PLACED IN HOLO: �- ry --�+ 4
PLACED IN REFRIGERATION: -
DATE OF CREMATION --
51 .
I TIME STARTED: , Lo? pn T:ME O M E E ;.56 DY1
PLACED IN RETORT, J rl s)sp _
---- _--_movep: ___ o�'I
RETORT - M\-I1 .1 LF�
tl IN WHICH REMAINS WERE CryFMpTEp; a I `�p`p��,K�� y� 1
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED M�.„A�HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE.. YTRnNON LOG
SHALL BE RETAINED N THE DIRMARENT FRE OF THE CREMATORY.
Authorization for Cremation and Disposition
law cm.mw.vat.,wwAllee k Awnw
1a a
ww.ao.re.
Tan AutlmrizaN Farm m be ust comp/efedaM elgrrtlpriorro diffini Offamtlne far
C cremation.
Date: 1%176 Number /0DU
Channel Name: Pi U Comment
l
Address: Quaker Road Ouesnsbury, New York 12804 Prone: 15181745-44n
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation is carrad! out by placing the remains more deceased and the container holding the remains into a
cremation chamberwherethey aresubjected to intense heatanaflame.The beat and Name will Ineinerso and
consume everytlling except bone and metal, when are all tam will be left after cremation.
Following cremation, the crematory will take reasonable efforts to remove an Mthe remains and other material from
the cremation chamber, but some minimal dust and residue will likely be IeM behind The crematory will separate
ncidemal and roregn material from the remains and the incidental and foreign material will be disposed at as
required by law. The cremated remains will he mechanically pulverized into small pieces and placed into a
designated container or um. Cremated remains generally are pulverized umg no single fragment is moogntrable
as skeletal ttlsue.
OPENING OF CONTAINER
The crematory may only open the container holding the urvcremated human remains in limited circumstances, such
as to confirm the identity of the deceased or to ensure that no material is enclosed which mght injure employees or
damage crematory property. N human females are delivered in a container al Is not vultable for cremation
such she a ceremonial or metal casket,the crematory will hall that the remains be moved Into a subable
container before Itacceao the 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 DECEASED /n7 (�
Name ofea De esd: /)a.Brycs. /c/v .j IS V>u WK AV! _s Manml Simon:�
Laat Known Address;: 3 O . R F . ) 13 Tr1Hffi C b a Y O
Place of Death I3 r 9 ti Ls. rill- ) 2 P2 5 ) Z'�
Sex: OM Age:4,DOE: IliA 17.a M eO : " FsBmeodVVSW
Descripaon of ceskeVcontainer in which moral will be "Whearelt
Comigetad Caramel Box with Plywood Stammrk Model If t88OS
PERSON IN CONTROL OF DISPOSITION
foareon(s) in conbol ofdisarewon, initial ONE of the following)
I ant VR are the designated agent of the deceased designatetl In a will or written instrument executetl
pursuant to Public Health Law, section 4201.-OR-1 ry Will have no knowledge that the deceased allocated a random instrument Pumuald to Public Health Law
eaation 4201 or awlll communing directions for the distomween of he or her remains and (ContnuednMppel
P. Q,A14ca uc io
aP4.108644 law. lLln Zma IXolosse Ppa1 M3
I am/we are the persons) having priority under Public Health Law section 4201 and have the right to l u ncrize
cremation of the remains of the deceased Myl(Dur relationship to the deceased is as follovn:
(Inson Man the let bekw) ((jj
Number: �Description. O t Eh-b
A person Mainstream In writing pursuant to Public Heats Law section 4201 (3);
2. The surviving spouse,
L. The surviving domestic center,
y. Any surviving child eghtmen years of age or oYJer,
4. Asurvivi t;_
. A smvivin siNi n rs of age or older.
S. A lawfulty appantsd guardian;
T. Any persons) &ghteren yearn of age or other entitled to share In Me estate and who iWare dpsem in
relationship to Me deceased:
S. A duly appointed fiduciary of the estate;
a.A close Mend or relative who has executed a wnilen statement pursuant to Public HeNM Law§4201(7),
10. A chief fiscal officer of a county or a public administrator appointed pursuant to the Surrogates Court
Procedure Act
10a. Any other person who is acting on behalf MMe deceased and who has assured a written statement
pursuant to Public Heats Law §4201(7).
()pfijglALL THREE tithe Aw wing)
3 . 6 Mae hereby affirm Mat Me body of the deceased does nor contain a battery, battery pack, pourer Cell,
radioactive Implant, or radioactive device and that any such materials were removed poor to the execution of this
Authorization Form. Failure W remove these Berns pdoT W cremation may mutt in harm W the crematory and
crematory personnel.
�, g• NAM hereby aMnn Mat instructions have Orion given to M••memo-w.el Stan Oeker #10159 regarding
Me removal of any personal property or charming of value which any person arguing below or any family member Mme
deceasedwishes to preserve (Oww ,o h P' V' C is not responsible for
removal of personal items from the container or"in Me remains of the deceased Personal Items teB In the container or
with Me remains willbe dMrayetl by Me cremation process and cannot be cautioned! after cremation.
S ,f Me hereby ammonite mwmwr m V PHISVIKOWCO2mablY W cremaW the
remains of Ma deceased.
FINAL 01S QS1f10N
The personuanonzed W receNe Me cremated remains of Me Oeceasetl from Me crematory is:
Name: tfaver FulgiralH Personnel
Address' 11 _afewdeat Shearefueen New York Phone: f518) 761-S303
The cremated remains of deposited will Oe disposed Of as follows'.
Return W Wmlly W be decided
IfLu any reason Me parson named above does rwt Wine possession of Me cremated remains,
(owssvi is subnormal to give possession of that remains
rmvv n nwre) BaX_5r Funerel Hama _by delivery in person or by registered mail.
p [y Un*EO Gi&g
IX06,1191 m••.mnol smwdp Pastas
'3, Wye undersforat that if the remains are not CI~wihin 120 days of cremation,
m.,a ",w Pine View Crannalory may capons of the remains in an menievade manner,
SUM as by scattering.
CRENIATION CONTAINEN1fLJRN
issuer dNF a rbe/dbMng)
An um to be used as a container forth¢ cremated remains has been purchased from
Baker Furred Home and is described as follows:
mym uncNstand unit ame um ISM small to hold flre entire cremated remains, an adcitional dgid contvner maybe need
fordefivery.
-OR-
B .An um has nct yet been purchened. lMe ulg mWnd thM if no um is purchased or otherwise pmvged
Imway,.,.r Pine Vl"Creboyandiv will place the aemaled remains in a first temporary
contairerfordelivery.
Thin Authorization Form was provided by aw,wwa�.mnal �] Tg RM C6'�`
was exewted at lrwa.i n�,a,.l k F IH
vmmiw,,..enem) I UMvmm $tnest Queensheary Neys,York 12fM and is aktnetl by the funeral director
as withess fo its evecetion.
Wse have received a completed copy of this Authorization Form.
The pessimist idenMretl below Islam the persons) in control of disposition, who by signing this Authortba on
Form, m t(s)to the accuracy and completeness of the Information comained In this Autbortzation Form and
authorize(s)the foregoing. (�
Signed this� \day M b1YdnQ b^
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Funeral Hare Reg. FU1130
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