Ballard, Edward Leroy Pine View Cemetery $ Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745.4476
FUNERAL HOME: __ gvw
a RETURN TIME:
DATE 8 TIME RRM41MS ARRIVED AT CREMATORY:
NAME OF FUNERAL DIRECTOR OR REGRISTEREO RESIDENT JJ3D Z3s
DELIVERING REMAINS:
NAME: �xpnn
—CASE p —_
TYPE OF CONTAINER: 1F _QN .
PLACE OF DEATH:
ESTIMATED WEIGHT OF REMAINS S CONTAINER__, _
PLACED IN HOLD: _ 2;
PLACED IN REFRIGERATION:
DATE OF CREMATION; -
-_ 9 LI 0
TIME STARTED: _ -"LA6Y1 TIME COMPLETED: _
PLACED IN RETORT; - :JE-yu14�-.— 9-- 7-
_MOVED:
RETORTpIN WHICH REMAINS WERE C CREMATED: '• —�•t--'PII,I
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN Re HOURS
FROM TIME OF ACCEPTED DELIVERY;
NOTE: TNe CREMATION LOG SHALL BE RETAINED IN THE pERMAKENT FILE OF THE CREMATORY.
e Of Stare
�-1 CelMmmen1 Of State
} NEW VORK Division of DIVi5N1^OFCEMETE2231 ac05
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°" Rl "'" Cemeteries
IDR1KRe
Authorization for Cremation and Disposition
TMe AUMadmUon Form must tes completed and Slgi prlarm Eellvery Ornmalmlfoo/r cmmetlon.
Date'. 9lrliby Number: •P
Cmnm Name pine View CryMAaxmM
Address: Quaker Road, QUeensbi NV 121 PMne: (518)745i477
°R5"TION IS AN IRREVERSIBLE AND FINAL PROCESS.
they ere Cremation
bjected Or intense s denied out by 'hand ano fie" The Fut and flame al111nclnS M and colure the remains of Me deceased and the cormliner nsume the en chamberains Into a crearnaton
marylMng except Iodine end
which are all Met All be left after cremation.
Following cremation,Me crematory rstll mks BRwable eflOnSN remove all of the remains and Other material myth the champion
demmbm,Out same mlNmal dust addrevdule roll likely be left behind.The pemalmy Ail separateinpdenW and ficasom mi from
tax remains and McIncdental and foreign material will be disposed of as required by law.The uemalee remainsMe wal par -rhino Ily
pulverized into smal l pies and plBeM Imo a designated cents ter m orum.Craamtl soma lm gnemll
single fragment is recognizable as shelval thowe
OPENING OF IS CONTAINER
The crematory mass my open the xmaioar.....I A . w--¢males human remains in limited circumstances such as to Carom Me
identify of Me deceased w to ensure MA no maereal enclosed which min Oman employees or damage the aemal"pmpedy.If
human remains are delivered In a conminer which Is not smmNe for mmanon such as wrx ial Or renal casket,Me
Manuel will require Mat Me "sells ber moved Into s suitable demands bosom It accepts Me remains.The opening of a
dmAwner or the transfer or removal0 Where will be canduckd derore a witness and waft be done M party.with diustr and seeped.
IDENTIFICATION OF DECEASED
Nameomemaved'. Edward Lemy B II rd Mama Smms: Married
Lan KnownAEEress 23 Grand Stma Glens Fells NY 12001
PIam41WOeeM: G F p' 00 ndS G F Y y/AS
iJ i
Sex'. MQF Age: 82 DOD: 09Hg1gag use of DwM XITMO20 Eaomaletl Weight:
Oescription of caskei which remains will be delivered.
WPAPAW loe.Rli rgl
PERSON IN CONTNOL OF DISPOSITION
(Persm(a)M c ...A W Wspavdon, . ONE of Me bLbwing)
enni We Me designated agent ofthe unusual designated in awill or wrillen insWment executed pursuant W Public
Heats t%N Section 6201.
.ORyy
INJe hew ro knowledge Mal Me Wasomsed executed amitlen Instrument pursuant to Public Heats Law Section 0201 era
II wntmning diroctiom for the Miam an Of his or her remains eM INe ere the parson(s) mvihp Party under Public Heats Lew
Sadlon401 and have the ngm to Washi -emel of the remains of the Mardi saysi u Uamhlp to the dacwesd Is as
follawa:
Edward Leroy BelleN
mwnwpw...N
00S rill f(Rev. OUlm Pagel of 3
Authorization for Cremation and Disposition
(Ines fed IN In(b9 W)
Number. 2 Dissembler:_ (✓qq
1. A parson designated in writingpformal Publictaelm Lane Saaon 4201(3):
2. me wMNna spouse:
22. }M sumvmg comma cremain
3. Any,survNing MAN eighteen years of age or new:
A. AsurvlvN9 parent
5. A surviving ei011y eighteen years of age or oltler:
6. A lawfully appointed guarcum
I. Any pwson(e) elgnteen"am of age or older enamd W sham in the estate and"a item cbsetl in relationship to the demaal
0. A duly appointed fidunary of the e$Wte;
9. A Close Mend or real who has executed a whips statement pumuenl W PUEI'w H¢91P Lax Samoa 4201 pp,
10, AMusef Mims OF car of a county or a public administrator appointed pursuant to Me Sunyap'a Coud Pmwtlure Ad;
100. Any am"person whole atling on behalf of the deceased and Mao has executed a wmen statement pursmnl to Public Heats
Lew Saudi 42at Ol
(IM/MaI/A�LL THREE of Me lamming)
yEA IAVe nweby affirm Mat the body of Me drommed does not coals a balpry, battery pack,power cell,red massive Implant
/ _an rad'wndam device and the any each mater ware removetl prior to Me execution of gas AumudmJmn Form. FailureW remains
�M�esa Items prior W cmmatlan may result In ham its Channel and Channelpemonnal.
Ines Nfvm Mat l nersefona have been gwen' 10 Math K. Pariah
/
regaNtn r the removal of any personal pmpaM or either thing of value whom any imi signing below Or ary%Milt'member Of the
derasedwishestopma , Pine V'pw Crematorium
is not annual forthe remoal of personal hand Mom Me mnpina message remains miss deceased. Psmonal Mims left In Ms
comers,arwM Me remains will M Mshopd by Ma commart pr uas anal wnnol mVNvetl tlarommatlon.
vk�&A? IMbhomb au arize Pine Vrew Cl abdum
W emmaa Me mmalrm MMe decnsaa.
FINAL 019P0SRION
Ten tee/ eau ners
me:W receive Macrenated remains Mthe tlewaed Mm Me crematory a:
Na tN
Address: 61 ma; - S+ Ali rc.11 l AP Phone:
This oilseeds rummer W dx owd wall ee dapassd a as Mims.
Axyng . ? AJ isk G,JL I I b C
If fa any reaman Me person named same does net take poddesslan Of Meammeted remar.
Pine Yaw Cre mUrn is auNosud to Fee Wssesalonof
tMremainsd G by and1Ve1y
M parson or et'registered mat
Edward Leroy fialard
WS-18real(Rau. Martinx.�wesxa Peps 203
Authorization for Cremation and Disposition
finial IM Mloome)
Il a MirsbM mist nine remains are MI aelmeE wnnin 120 days of menial coy
Pine View Crematorium may dispme Of Me mrmiv In
an lmenemble manner. sutlia9 by SwWne. `e r
CREM MON CONTAINEMRN
An um 0 be mad as a(Un ener br the amneled remains has been pumMsetl Min
aM is tleaGiOed ark blbwa:
We uMessamo that it the um is am Small to bold the entire oriental a lm, an edd2Wel rlpld cent may be market for Manner.
-OR-
ZaAn ism S not yet Primmer INYa undeMeM Net it no um is puMeeed or Menem prove ed
Pine View Crematorium SH pain Me Uamaled mmeins In
a night temporary¢nblrer for delivery. .�
Has Autlro atlon Form was provided by Mark K Parish waaemculed st
Carleton Feminist Home, Imo.
68 Main St. P. O. Box 67 Hudmn Fells NY 12839
and Is signed by the funeral Meador as whimse he m emabon.
Il have rearmed a compel Wary of this Amendment Form.
The personal IdeMlled balow Islam IT Ponmte)In tonal M dlepoFl6on,who by elgning MIS AUMotlmome Form,afte i
b Me asi and mmplebrnaa Of the Informtlbn conarred In MIS AuMmxago Form aM aothodxeai Me formaoing.
Signed this 18 dayof August .20 20
Eit en Ballad
23 Grand Small GI Fat Fatill NY 12W1 T
rauamsuxrn
Opi I Owns, Seem
WnNESS:
Mark K. Pariah
p�Ip�'M�31
�m w
EdwaN Leroy BallaN
WS-189i Perv.Oil Page 3 of