Beebe, Rosella Mary Pine View Cemetery 8, crematorium
Quaker Road
Queeasbury, NY 12804
(51a) 745-4477 or (516) 745-4476
FUNERAL NAME:
- "--'- -_. RETURN TIME:
REMAINS
DATE B TIME - -
INS ARRIVED AT CREMATORY;
NAME OF FUNERAL DIRECTOR OR RECRISTEREO RESIDENT DE
LI m(N1 Z
ELIVERINO REMAINS.
NAME:
-- -[±P3sug
TYPE OF CONTAINER: _ /ll�'OMI
--��CASE p
PLACE OF OEgrH: .._._11 --------
ESTIMATED We1GNr
OF REMAINS 8 CONTAINER___ )do
PLACED IN HOLD: "� '
------
PLACED IN REFRIGERATION:
DATE OF CREMATION.
TIME STARTED: ' ---/� .
---_TIME COMPLETED: 0 --
PLACED IN RETORT:
'!/�v;�
RETO • MOVED:
RT p IN WHICH REMAINS WERE CREMATED: _ --
DETAILED REASON FOR DELAY IF REM
pINSWEREC M TA CREMATED FROM TIME OF ACCEPTED DELIVERY: MORE THAN 40 HOURS
NOTE: THE PpemRnpR LOG SHALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
n State
NEWYORK Dewnmmt instate
on DF I �iVIsiOR Of Dlvlslo xn:n^enEa".
° Cemeteries °nr ° `mB"
AIW.Y.NY1 alaadl
rd.ea talm4,..,ea
Authorization for Cremation and Dlsposrtlon
This AUMOr gUon Food must be cwnpMed and signed Color to delivery of remains far cmmatln.
Dine. 161 t0 Number.
Cremetivy Name. Pine View Creed dum
Address: Quaker Road Queembury NY 12804 PMne: (518P45-04TT
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cm w is limed out by INal Me remains of the dewa ed and Me communist holding tM remains into a candsonc ae r"am
they ere sub/ to Intones has Am hOm ,The Mat and Mme will InWftmm also Consume aW IN III bone and mmal,
which are all that All be loft after cnmatlon.
Folio ing cremation.Me crematory job lake reasonable Arms to remove all of the remains and other humid from Me cmmoon
Wmber but some minimal dust and residue WII likely be led Pan Ind The monaldy will separate mutlnlel and for metmal Rom
the remains and Melncconed and foreign nwtenal I be di$Ne of as reyured W law.TM cremated remains Mil be metlunlI pulvell Into small Pie $and planed into a deelgirl mn4i nor or mr Cremated remains gemm Ily a OR putwdeed ue4 l no
a Ingle M1agment is recognlrable As$BoleiI tissue.
OPENING OF THE CONTAINER
lM1a Centel ma wrMimr n holding the uCo make human remains in Ilmite w tl drmstOI such as wein bn the
Identity of the tlerey only Open the sect Or to ensure Mat no meWhal is Call which mi Injure employees or damage the crematory prowdyr
human remains an delavered in a container whim Is not suitable for crematon such as ceremonial or mndel mkeL lie
mmamPj wlB require Me Me mnama be moved Into a suitable ammnm before it accepts Me mmalm.The opening of a
Container or the transfer or Prmevm a remains aid be Conducted before a witren and ofit be done In Anal with dignify end respect
IDENTIFICATION OF DECEASED
Name of Deceased: ROBINS Mary Bttbe MedMl status Widawetl
Lastxnowm Address: 270uarry Crossino HudsonF II N 039
PIeessoi: Glens Falls Ho rprol IN Park 51 Glens Fa s NY (tU I [[''Sill M ® F Age: 83 DOB: Offifil a Disoo/DeaO: ONI&I Estimated Whose: Fd
Casmptiw of coin eVemrdlner in which remains will be delivered.
PERSON IN CONTROL OF DISP SIathi �O
TION
(Per jhjl M ronbd of Napwrim,WHW ONE d the ldlmnn ig
Ien✓We are Me designated agent of Oe musased designated in a MII or w Snintlmmed ssecuted pursuant to Public
Heats Lax Seotlon 4201.
R
INYa love no knowdd0e that Me de¢ased execNed swr len Instrument pureueMto Public Health Lax Section 4201 ore
Me
ftm
his a her
5 'Mleo 4P01 a or onet NMee r o gMlo abefthrimfcemetion of thelns and remains of the derm are the eaed MylOurinreati nito'Public Health I-jus
Me deceased as as
blrawe:
Roaella Mary BeeEe
Manwaoveapl
DOS4890d(Rev. OW15)
Page 103
Aathodzation for Cremation and Disposition
Unman M1Wn the per oelcwf 1
Number:_ oeecratedcJs. , 44/
1. Apeerwnrv0ergnser in writing mMUOM W Public Heats trx gwdMm 4201(3):
]a. The eurosing Moral paMeo
1 Any surwNng chits eighteen warm of age or older
a. A sururving parent;
5. A wrvrvmg sibling Norman years of age or alder',
8. A model apPOMW mandian:
L Any pnaonla) didderen yeam of age O ol0er Named to Aram in the Maple and xio lLare dos"] in TklionMlp to the dec W:
S. Aduly appointed(iduciary of the estate
g. Adose hand or relabel who has exaculed a written statement pursuant to Pudic Health Law Sedion<R0IM;
14e Acb'ml fi lolgcer om WunNOr a publicedmmigrator apartment pursuant W Me sumpme'a court Procedure Ash
Any other person whom acting on behalf Of delta d and ono has exeWted a wrigen stalemem pursuant to Pwlm Health
taw smlon azel(7).
Xel tiiAU THREE ofine/samor )
'We nudely afirm Nat Me AWrdMe dew does M common a surgery, many bock, powereal radhectiveimplant.
///Or radical device and that any man materials were removed prior NNe"Hotel duds AumWzaYon Farm. Failure a rased"
these Items prior nemwto a may result In hand to By members and nem$tO y personnel.
xiIL Mealfirm Mal dnsNudens here Integral Mar Lri-5h
regarding the removal of any Igraonal pasarry wnMx Ming Of relue"Ii ant person will bee"or anyfanly,members Its
demaeed WNesw Weseme. Pine Vies Crematorium
is net responsible for the removal W pxsorel Items hose Me commner Or from the remains of the Miami pe nal Isms MR In me
ontaler or with Me emaee will the,desb i sy the cremMOn Manuel and a mad be mMeved after cmmallon.
,&BLime Thai euthodze Prom Vlew CremaMom
i�Mxrnvr
e CMMM the remains of Me dm"sed.
FINAL DISPOSITION
The POMO�/n� notoua to r ive his cremated remains W the demaad from the damaged".
Nam
Address. VN AN Sh Nud rlr /? �Pnane Jr�-may
The demands! remains Of(general vall be disposed of as hurt
EN4e.w.4w,,.,,F nF $ Jg
If for any reason the parent named semi does net aka paaeaum W the UmdM remains,
Pine Ymw Cremamnum bautW edtogimf Sn enW
thedmgl C Nrrarw wner:rny moelivery
in point or dy Rgistered mail.
Roselle Mary Beebe
DOS 1888A(Ray. Still 5) wmuw�l Phyl
Authorization for Cremation and Disposition
(InN&Ihe Mlovingf
bWe unUentenE tMilllg remeina ere nor GaimeE wI1Nn t2o Een olcremNion,
Pine Vies,Cremamrint maydispcae Oltberemerain
an urelnevable manner sucn as by prepared.
CREMATION CONTAINERURN
mrp
�An urn lebe uSM wrneinerforinecremateE remains has teen WOue hom !kJ heirs
ardsvidescrithella,folows 54L& Rudir oggi
take understand that Nme om Is led small to hold the en&euemaled remama, an Seasonal Apia weather may be uwd material
-OR-
An on is net yet puraleaed, sake understand that it no um is Permitted or othervnee provided
Pine Vlaw CremaWtlum rill pipes the cremated remains in
a rapid temporary wntainer for delivery.
This Aupronzatlon Fmm wee Planned hey Mark K. Pension was everi at
Carnation Funeral Honle, Inc
BB Main St., P. 0. Box 67 Hudson Falls NY 12839
and is Signed Oy the funeral character as weeks to as Eastman. m
maps false remived a mmplmed wpy 01 this AumwBanon Form.
The pear lldanYflW below Islam the quOeal In wrNpl of dlsmoaltlon,who by signing that AUdvalm nFomy aWpNsl
W Me Social and completeness of Me Information conhlMe In MIS AUMWhasm Form and arehorlulel Me forievord .
ffignardMb 17 "yet August 2020 'l� ,"1 1\ I i la."4tk
Ravrtimw^e
WITNESS:
Mark K Perish
LlVL
I �
Roselle Mary Beebe
0051898 f(Rev.08115) Pape 3 of