Black, Florence A Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERALHOME:
' _-__--.. ._ _ __
.._. RETURN TIME:
DATE S TIME REMAINS ARRIVED AT CREMATORY: . _
NAME OF FUNERAL DIRECTOR OR REGRISTERE RESIDENT D�IIVFRING REMA�
INS-
NAME: Bb —CASE q _
TYPE OF CONTAINER:
�9` -
PLACE OF DEATH: Y� -� 1� 1 �IA(Pfr
' I IIIhfMry�,�_— .��_ 4
ESTIMATED WEIGHT OF REMAINS S CONTAINER__„
PLACED IN HOLD: L�f
PLACED IN REFRIGERATION:
OpTF OF CREMATION:
TIME STARTED: _ Y—wft TIME COMPLETED: _ 17,6pr)
PLACED IN RETORT:
RETORT A IN WHICH REMAINS WERE CREMATED;
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN yB HOURS
PROM TIME OF ACCEPTED DELIVERY
__
SR
NOTE: THE eREwpT1O N LOG ALL BE RETAINED IN THE PERMANENT FILE OF THE Rc EMniox
De deOOs
NEW YORK Division Of Dmmom OF mums
srAteov one cammere ion
°°PORT"NI^ Cemeteries 99 " °tar blow
Afti W122ndoor
hectares, 51811 Oa6R2fi
Authorization for Cremation and Disposition
Tple AuMwlntlon Form must M compM d anEelgnM Prll delivery Mremairn braemetlon.
Dow 8/16/2020 Number: JqJ
crematory Nam. Fine Vim Crematory
puayer Road, Oueennoury. W 128N 516T4S
Address: PMre
CREMATION IS AN IRREVERSIBLE AND FINAL PRWEW.
Lremalion is tamed act N places Me reneins Pat to deceaud aM Me dethird hWiN Bra retsina add a cremation chamber vfiere
May are subleded UP intense nowt and fame. The beat and Reme sell Scandal and Gansu ev ing excel bade and ma .
which am all teat will be left aNr crema°on.
Follwnng uemat'nn.Me thermal will here reamonable all to wedged all of the remains aide ether rnamdal from Me commerce
Tamper, ban some minimal dug and residue sill likely be left that The mahogany will separate enga ed and forest matenal from
the remains and the Incidental and brngn edgers]will ass diepoeed gas regWre l by how. The downward nmems unit be McUenlogy
pulvmaedinfonr lsetaeandpm dIntoodessngddcc nerorum cmmamdremaimpnerallyarepWwrimduntilno
shale fragment is ncagnD blau eblgal tiuue.
OPENING OF THE C°NTNMER
The crematory may orry open the container holding Me unvemeWd human remains in limited Prramgates, Prot as confirm the
identify of the dettesed or to ensure Nat no material a enclosed which might injure erriameav 5 or damage the mnabry model If
human remains are Nllvswd In a container which to not smingt a for cmmatlon such as wlemonlal w rental corm Me
abry will acquire that thee remaire be moved Into a suitable container hall accept the remains. Theopeaingde
co Mmandr or the thwart«anaval of remame sell be wndatled fears a wMe»and will be done in primary, MN dignity and respect.
IDENTIFICATION OF DECEASED
Name of Communist Florence A. Black Mang slaw. Married
dog known Address: 77 Tarbill Hill Lane, Long Lake, NY 12847
Place of Deal residence
Sax: OM Ill Age:72 DOE: 11/8/1947 DatedD 8/15/2020 EehmaWd weiem.. 170#
Dexdpdcn of cmkeVcm rb ww rem.tm sell they Methodist
MacDonald Container; basic cardboard cremation container with no interior
OF DISPOSITION
(Persm(a)mwMMo1d'apmwr "hal ONE a ma/dfowtng)
I arr✓Weere 1M de9ggw1 agent of Me demaved designated in a MII or i n uncommon aACNed pursuant to Public
most law Section 6201.
IAVe have no Midwest than to de¢aaed executed a winter,instrument pursuant to Public Heafth Law Section Q01 or a
Wit Wnlemng duredges tar to manager of his or her remains and Ilse are to persons) having pasty under Pubec H with law
Section 4201 and have Me ism on eutw¢e uemgion of the wmaly of the de aged. Will relationship to Na Mcuwd 4 as
follow
Florence A. Black
DOS 18M f ter 08115) Page 1 of]
Authorization for Cremation and Disposition
alb(ImT/a�r M�e fa'bxvg)
a ldNbIM1V¢understand tied Mire remains are not thooee witliin 120 days of arearal
Cremetery
may Maame of Me remains in
an in&nable murner, suCM1 ea by s ooters. mrti nd�a
es
CREWMN CONTMNEMURN
(L ONENMa moomfo f
An an to be used as container for they oemadd remains has Seen radMead ham
and is WAinded as follows'.
men unarslBnd Nat if Ms um is M1n amyl w hold the a ndre amended rem an eddhil dmd Ransil easy be ua¢d or"Many
oR-
AnwnNmlyNpwaased. eLverwemmnd Netrcm um NpuMemd protnemMe pmrieed
remaa
wie PlweMe mmmtad remains In
^ m', iko
a ned tempoary wManerM Wharry. e
This Audmsiza Form w:prmiaed W Patricia Miller "a mower at
Miller Funeral Home rF.womx.�w
M7 NYS Rro. 30, IM'an Lake, NY 12E02
and is signed by Me Nnenl director as aftnms to Ad execution
]Me have re eir¢d a completed apy,of Nis AuWmiaatian Form.
The penania)Id"Med below Wary Me Oanonie)Indemand W dissoeMon,who W signing Mls AuMosea4m Form,at si
to Me security and comgebreee of Me IMormetlon contained In are Authorizatlm Few and aumoduts)Me foregaing.
caned ham 16 day ar August p20
Colburn G. Blacks,, .,
rPO Box 661, Long Lske, NY 12847 —
WTNEdvSv:
Poncer Miller IrIp¢rn srmrvrara (amm.JM�
12K5
Florence A. Black
Wei Ea f(Rev. M115) Pegg 3as
Authorization for Cremation and Disposition ,
Onminom na M4 narow)
Nambec 2 Dewhptmn husband
1. Aperwrdesignated In wnung pureuamb Pubic Heats law aerAon 421
2. The suer arouse:
L. The fursol domestic partner:
3. Any survmng child eighteen years of age or mass.
<. Asurvtdrg parent:
5. A survwirq sibling eighteen years OF Me or alder,
S. Al awfully appointed gu man:
]. Any rarsomm eighteen yore of ape or oldermlHkd or share In Me estate and who iMare domain In reletinwbip to me d so:
8. A duly ermined fiduaery,of the estate:
B. A does Mentl a relatim who has exewlM a wham statement prowanl to Pudic Health Law their 4201 in
10. A duel fiscal officer M a murdy,m a pubic administrator appointed yel to the Sunni is Court Procedure AA:
teal Any direr peron end is acting on behalf of the strimmd eM who may m osided awregin stM ent Wreuant to Public Health
taw Smooth 4201(7),
(In gil/&L THREE a Me ra4oNwg)
(�dIMp hereby at5nn NM the body rfMe de eased tices not contain a battery, haMry pets,power mill, rWichowe Impknt
ormleadlve dmr¢and that enyoudi matergb were removed prior to the eaearnn oltMS Autl imdm Form. Faeuretomnove
these mama poor to mmatlm may result in ham No Ue crematory and concerns peAon et
_ Aft affirm that tmm,cwns cove been glen to Patricia Mi IIsr w a.
regarding the removal Many well pmpem or other mine of values wh on any person curb below or any family member of the
Pro ribleve Crematcry
cheesed codes to preserve,.
is not responsible for the minimal of Poresnal Hems hen the consent or hwn the remains of ore Mxawd Perwnal items laX In the
comalner or MP the remalas will W Medicaid by Me cremailm wmdw a and manly ba raMBved afar cnmaion,
PPeY Chanel
IN3e hereby martins
ownwim, win
to cremate me remains onhe deceased.
FINAL DISPOSITION
The Person accused to rxerae the vmmted renal of tM dam man the Permit is:
Miller Funerel Home
Name.
8357 NYS Fee W, Indian tab, NY 128,12 518541A.0011
Address: Phone:
TIp pgnMed remains to dimagal WIl be dp Mas mlMvae:
returned to Colburn Black
If Or r(ry,Meth the flown name Orion drca cal take possaaon of the aamted remains,
once view Crerraary iseNhwwgwpaN d
Me remains to Miller Funeral Home ba"Nv
.ww
in mason ter by registered mail.
Florence G. Black
weneucma
DOS-1868-f(Nev.=15) Page 2 03