Mercier, Raymond W. Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (598) 745.4476
FUNERAL HOME _____._DPN
-----.-.. --- ., RETURN TIME; __ $
DATE A TIME REMAINS ARRIVED AT CREMATORY: -
4v° b
NAME OF FUNERAL DIRECTOR OR REGRISTEREO RESIDENT DELIVERING REMAINS:
NAME
--__CASE p
TYPE OF CONTAINER: ,
PLACE OF DEATH: DYgF_
ESTIMATED WEIGHT OF REMAINS A CONTAINER
SO
PLACED IN HOLD: '----
PLACID IN REFRIGERATION; _-
DATE OF CREMATION:
m
TIME STARTED; 7—TIME COMPLETED: �[�M 2:YDP
PLACED IN RETORT: '•ib p � UFOn�
Qn__movlD: 2D5
RETORT =�-
p IN WHICH REMAINS WERE CREMATED:
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN q$ HOURS
FROM TIME OF ACCEPTED DELIVERY;
NOTE: THE CREMATION LOG SHALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
r
uPpm.mwk
SATECIF Division of �
SIFTED
"UNITY. Cemeteries `rnrth me ;,woo,
Twitimm, mmeuaaae
wirwile.ni
Authorization for Cremation and Disposition
Thi.aNMNANon Form must m completed and signed prior to delivery of remains for c,amauon.
Done-. /^1`^ � > uhli Number:
cremxory He ma Inmewcnmxmun
Abpreys kl Quaker ROM, Ouprad,ry NY 12&4 PMne, 151p i<SMTT
CREMATION IS AN IMRMRSI EANC FINAL PNOQE
Cremation is tarred Out by page tie remains afire depapd and they oTl.ms Mdrq the la,Nns,m a eaWpin chamber
M aresubje tolmmsebsatand5ema. Tie Mxandtime WIx MCIpnb Ma Corsunew.rvml bowand n,.Yl,
which.nall Met w,ll be M ANN CNnedm.
Follow ng cremation.Me aemxory all sure rea&Mableefforts to remove all of and emalnos and other mxpalM1nn tie U madon
chamber game anm in at dux and revdus will IIkedy be left Wind. TM gamin wills rate answered may foreign meddal Maim
No
The
pulvenzedsiMo email places aal M placed into a deslgnmMm dispoirMa esngw�bteydlaxr it gomxp .n Pula lwi until eramM
single hipmem N rxagrN p.kxxalYpw. un
OPENING OF THE CONTAMNER
The vematory may only ago me normal holding the uucaga M human remains in Baits]amendments all as m nnfirm„
identity alma de amde �ri�enauntlute erwhic Is mtlwad'Mlef mightinjure emp�ine�sordamsge de dental
W1g Mff
humanre will an oat
at M mawm W mohlennt nM.whaxe crem.pm each..ps pre
u.bttlw
�m.bry will ngmre Made remxp be moves into a suitable re awtManaging Mon n.cppbtiePainremains. The ury ialand old
mamerortMeanarerm remwel of rem«ns vdn M mndmted betmeew+ee.ame lu M Gone In papa, lm d�OnM�end n.pe�a.
N `^_f___.. ° a IJ a'�' I 'eQ Mvi�lel/1smr.f✓"""`-
thin) mH i 1'/ c fir. .N R 1 ,
Raw of oa.M: i1LL blIR;r-
Saww EM OF AN, 50 oe 5. 2or HY actLanI od> E.emxMvapc ls_/Ls�
Deaaiplbn or®ekatlanleitrerin viticrt mman wall bedx'rvNed.
1perauT(elh^con,rot blraspw2m, �WlEdare ronowmgl
I usage are tie deslgnxp game M the deppe]dpgM in a 00 or want m.tmmmt RdadM Nr nt M Pudic
Health law SM m420t.
R-
NNenavenaknowledgethatmedeceamd"P awrlMnINtrument poreusx to Public Health lbw$MM.n 4201 or
all containing diredime far the d5posmon of his a Mr remains and Ile are to p (s) temg pribny under Public Health Law
SMIM 4201 and hand the right to mundane mral Of To l 'm Of Me dexasw sludge bonehlp to the deu aft As
iylj�i Cie
Nlwre
R"
Oi 1 F381(Nev. ON 151 page I oft 5
Authorization for Cremation and Disposition
pnxanom menafbddwf
Numbs, oeempm 5. C4 Iq
1. Awe EmgmWinw n,) as.+llta HaeM lax Swtlwi1N113):
2. The Whose spouse:
a. That euMvin9 eomealk PaMer,
2. Affa WMvinatlnit tigMaen Yreraof agew
S. Aauriyon9 prenf
S. Awrvilliy spibl'mgepMeen years olage or Oft
G. My Area spectral al yearn:
8. Any ly III91&gMeen real arry 0 of age or okerentltlmbaNrelniN Belle fill MOlerare tloaeal In relallmMlp to the EereasM.
Me estate
9. A mp merd or reabve wlp has execWel a anted elalemers µRua b PuYW Health few Section 420117)I
tar. Abody Mesa Officer M a county or a poetic achmmimalor amended reveal b one 5undefteS Chun ProMun,A2
Has. My dherµ on yell is among do Wood W We dxmM add xlw Ns azeboare a where 9ehmers lemons to Public Head,
Law SeMm 4201M
{n�(yfag�a'AU THREE dt baseball4I —e_IWe hereby affirm font he hotly or Me ayearded Mara prof mMam a eaXery. mattery Wsx dearer all, raaloamve neither
or rabmaNve Moved and Mat any soon mafehalc vary,remove]pNrto Me erecMon of this AUWomrstr nForm. Fanunto momr,
W Mords Prlortacnmabm may muX In herm to Xp vamanal and crenMry pommel.
N'b*-- WM affirm MN InNumma her bxn green M Rahaf 1. NMMm �.rvwu,.ww
arga ing fM rcmcval of any rams p'gvM or Model this of"We ya lcn any person 9igning body,or any amity member d the
oesased Manes to preserve. R BwC dwxm
is not resmndnle for Me removal Wondered Mora 0ln MedonreinN or mom the remains ofthe threaten Perawul XemaleMInthr
' lylcmo�nttalr�evarwon MeremWN willbdWVayed bytle cremaeon pMceY and cannon MrevlevM eher cremvtlon.
yi IM'e lenby auN m Parenew Cmmalonum
!J to
cremab the ermine of Me Mtt w.
FINAL p3PO9RION
The prxn Montserrat M xeM are mmBbd normal done aaexM hard has Mandatory b'.
Name: Riled l' fMlemm
Ad]reas. 7 SNrmm Avenue.CaiMh. NY 1=2 offers sl&5603SX
The mma4d mmavw a aawaem via par eypp]a u MPL'.
C- 5ws a. ri, tA
If M any random the pram rwmM abxe does not bye pwenaM d the wemaea remere,
Plnew"cmlamdm Iaawnrsad No goner wOf
Me rman9 toCmmae Fmn9 W.ae. l rwie MaNlrxry
MiaBm or W ne teed mall. AA��
A /' lerc'c.f
o Mwfhf(Rey.mist ucse thel
Authorization for Cremation and Disposition
�Ne Mbwmy
IMh umemm�e mal egsa rem.im.m rotaaimee wgnin t2o mn diemdwn.
P.nr'rewcrenamnum may aeWxdnnremelnsm
an ineMmade manner, oust as by svrhani down
s a�—°N
EUNe MIorvMg)
An um to W host he a CenMMerM We mmabd remains bm been WrSmNM1Cm Oemmbm FunSN Holes.Im
IMIe unporeleM MateNe un MMo mall W deb Me enWeaemaW mmsina en s]Eitibrel rgticmrY.rermry CouldkreeWery
Op-
An um Is rcA yai Wrtl'®sl NAIrSNaISbMNelif rro un b puitlam!wdlnrxiia growWe
Pinmew Oremalonum Mil plane the ohnn eC remains in
e npN Mmptr, ary Mn4 nerlMeNMry. awn �
The;AueroNNur Foms"S pvnCN M RsterlL Oxuniva Fwaov .r cone evxul Jat
pensmwe FMeml Hine, Inc
Slpnren Avenue, CMrM. NY 1=2 p,.wresxav
pirwneard
aM it signet!by Me Nm21 enttbr as'Mlw s b II9 mearAl' I.
IMIe nave neon an a¢mpleree copy M this ANMrlmean FPrmThe pracont )teeterd behove not The .
this
bthesecuriity aM Csinyblenma a bw Nsmmetl)Mn tormented in the A caysitil of tlpry��mo�sFarsO a aAUIMNeIs)Me foregoing Osl
agneE this �gay d A- lam ` .2g AV
O F�Xa�L)r+F/eI_snihm ��o� J
Wtirlel :
holiest I nsmom
iosto Lam- Ali& C2
pw3da
M&lIyh4l(Rev.M115)
Pine View CemelciY and Crcma[orium
21 Quaker Road
Queensbury, NY 12804
Authorization to Separate Cremated Remains
Funeral Home .....____.pj_NS^_�= ______ _____________ _______
__
Vwi amLorixc [INC wParautal or JmgacnmmJ mnrvns of
____—___�! -Ka _— ---_--------------
Ow
m Lnhl Lmn:lcv, indnm 'f mJ ddcnd Imrcln cJ c: nalmium ae well
weYin w Hod iou all�drninrs, l'u )I40Cx or dmuagc%w6:axoaac whld: new
.0 d r.cD:eumaiiven, kom
enht liom iLix auJmnl.aiion. -
sitrv� --- *
Gem:uop' OlMnurn _