Piper, Joel fine View Cemetery 8 crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL Home: .p
—� -- ----- __ RETURN
DATE & TIME REMAINS ARRIVED AT CREMATORY: So
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS-NAME: ....___.._-`1EL`.._.___ _
C CASE p
TYPE OF CONTAINER:
PLACE OF DEATH: (rEe¢AT Nn JU f
}
ESTIMATED WEIGHT OF REMAINS S CONTAINER__ _
PLACED IN HOLD; 2;K tie
PLACED IN REFRIGERATION;
DATE OF CREMATION:
TIME STARTED: __ _ : IO"_ —�
TIME COMPLETED: _ If0
PLACED IN RETORT:
v 116
RETORT pIN WHICH REMAINS WERE CREMATED; � ��
DETAILED ftEg50N .__
FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURB
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SHALL BE RETAINED IN THE PERMANENT FILE OF THE CROMATCRY.
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Authorization for Cremation and Disposition
This AutlwN n Form must be cwnpl addtl W prior b Rive or meeting its cwn"m
_August 19.MID Nwnl 944
Crematory Name: Pine VM Cram
Address'. 21 Quaker Road Ouions[urµ New 112&4 PWne: 516745M77
CREMATION Ie AN IRREVERSIBLE AND FINAL PROCESS.
CB ion is denied col by plating the remains of the mainstream and the tonteinar holding mere aura iMO a rival dmrmwr Minn
they are embedded m intense heat endlnme. The hest and Rome will imimmw and movement averMm9 except MM and enable
wMch am all that will be IM after anmafion.
Fodder Ing memation,line crematory MII all hu morable all To remove ad M the remains and all award farm the monsoon
argument, but acme minimal dust and residue and III for led behind. Two morn ry win wpaele intidentel and bnign nalenal from
the remains and the Inerdental and brei9n m venal MY W disposed Mas repaired by law. The Ransil remains will am mecheMWry
payments Into small p m les and pill Into a designated m mineror um. remains nalns W"mil Inrial all m
will Ragmen is rw nimble on aka iflmw.
OPENING OF THE CONTAINER
The normal y only own b%water holding the un-vein@d human remains in heated orcumalancos. well as to confirm the
ideaN of the prodwased or to ensure that no mMenal is andwed which mild Injure employees or damage the vemstOm PmMM if
human remains am delivered In a carwiwr wbia is not suitable for minimal such as ceremonial or mrtah cake de
mnatmy wilt require MMTe remains W moved Into 8 sublabN consumer Wfare irnnpb Me mnains. The owning et a
mntener arms tranafer or removal Mremens MII be conducted Wow overseas and MII W done in prrvary, wi0 dipay and reapxt.
IDENTIFICATION OF DECEASED Named
Nerve a CeceasM: Rod Piper Marital Stales:
Last Known Address: sO Louise Lane lake Goo es, New York $dam
Plxs of Death:00 LWIse Wer lake Dewge. Napa Yak ILST
sea: ®M DP A9e:54 DOB: 09-11-1965 Dairen mMn:08-18.2020 EMimete MOt 150
oeauipecn of kW nx in winch minim vein be dminred.
Florence Casket, plywood corrugated cardboard container.
iROL OF D SPOsmoN
fperam(a)a ronfMOldepovYron, vuy ONE o(Me IdbwNg)
I a nWa Ye the designated agent of nor dK4and de pre sd in a up v wiWn insWmeM wo dlled Renewed to PwllG
Human Lew axdan Q01.
-0R-
0 If have no knowledge Nat the Remains exewted a written Instrumen WrauanM Public Health Law Section 4301 or e
MII mnraineg shot a for the diswsAon of h18 or her remai w and IMY are 1W perval model Priory a tiler Pu il Health law
$Baron u01 and nave me vein t0 aumod¢vemeeon mnW nmunaol Ne dewaaea. My our nlaronshipta the deceased w as
fellows: Joel Piper
Page t of 3
of BR I(Rev. 012e)
Authorization for Cremation and Disposition
lLMla the Awkwa vl
1 iMb understand Mat ame remand any red claimed within 120 days m cremation,
Fine Vbw cremarory may anyone otMe remvne in
an lrr evade turner.short as by wl na. emmcm+en)
CREMATION COMNNERWRN
Saint ONE of M ,Wamag)
An use W 0e used an e cordaner by Me aerreW mnYn ,Na been durclined M1Om M. B. liiM1nM FUrydN NMO
and isdeemeedas Mims
-
Ii understand Mat IF Me are Is Me emtll to red Me miare venalea remains.en aMulunal Mid contalrcr may to insist del'rvay.
-OOR--
so p
r ?-y � AnumlanNyetPU"a . may underMvid Met it no um is purtrteeed or otherwise attended
Pine Crenday will pkce the crowded remelne in
maid temporary wMainer for delWery. r»� u.rvn
This AUMwlnaon Forma pmrldea i Cat C. Konoplia pW.romx.�e was executed at
M. B.Meant FUMraI Home
1 M Main St Bound Glens Fak New YCM 12803 nwwm..x.A
and is signed thy the Nneral dlresar an vMreee to its execution. mee
news have reMived a 0.mpleted why of this AUMWlntlen FarneThe .
g Min AuM�zabm Forni
bMe°accuracyAnadcamnal penterers of Me Iow share the nformation contained suspension,rseens) In control ad Min AUMwlaatlon Formin and Interests)Me fwegonsi sl
Signed Min iB sandy August 3020
FnneM adder
MIM
when
rhed.0"i sense
WrtNEBS:
Claire C. Nospya
ry nmvmm� Y w^+^1 Y
am932
sami,nm Joel Piper
OOS 189"S e r O420) Pas 3 of 3
Authorization for Cremation and Disposition
m ut tho,Zfio roFL
Number'.2 (fescipbon; The wrvrving Spouse.
1' APoraM MiBnelea In wrong pursuant b Pubic Had"Lew S9tim gIh(3i
2. The auMWng Spouse.
m. Has surviving do ShC corms-:
3.a Atumr 1V1ng Any eighteen Ham of I Or over
, :
g parent:
I. Asurewina sibling eighteen years d age or order,
8. A III appointed guardian'.
T. Any n(s)eghteen Few of age or doer entitled to Share In Om Suds and who saran ckuest in Metimedip to the aepa¢ed;
S. A I appoided Xdul d Me elate;
9. gdose Mind orreletive who has exewted a written 3Ma nt purance b Pudic Health Lew SeggM201 Ci
10. AW'mf Aral ofiror of a county Or a propic administrator appointed pursuant No Me Sumpete a Com Pro¢oure Act
IN. my Other persin who is acting on beluX Of one deceased and who I executed a wnXen Shortened pumadb cubic Health
Lary OeGbm a201P).
Mali ALL TFYEE d the recomg)
QL—i hereby affirm tied the Iwdy,d the aeaaeed dome nor contain a ba , batlery pack, dower¢y mlo "'mpt .
or mdpadive device and that arty such matenam ease renerved prior to one me hm d how Autl dm"n Form. Failum mremave
thapn tame poor to cromation may result in harm to thin Cmmatwy and GMM=q pmmnnW.
rv00 IM'd I MM tmlnuchons have ten the,to Claim C. NMcpke
regarding the removes of any Po Os 1prapeM«dhx Ming Ot I whaM1 any perm$far, ceWw or any famtN member 01
Uxeeaed wishes to Preserve. Plne Vi Cmmatory
�e rent reepmaible krtM removal olpeROnal ltemahom tM¢nminerm hOm Me remains ollhe aeceaeea. Penmellm slm mono
�conmnewm Binmmain llbedSs"yedtythecr &VOnproaeeandcanmtber evedagarcMMtlon.
�' hWe hereby SIMMONS pre VIM Crematory
mae.dmw
IIM1WOPnONAIJ mrnm.mm.mmairm mine wC..w.
We hereby amhonu Me named funeral Mother to provide fin ddlvem to and cm 2VOn by on almmam
address ore cn tln attic matM. Opinion Of the funeral almno.. arm b amend this ram SO Praula the Dante name and
FINAL DISPOSITION
Tinpeoenauhmhed to receNe the oe Min remains of Me deceased Iron We oe n lore is:
Nome: M. B. Kikner Funeral Ham
Mdmu. 138 Main St South Game calm, N&I 12 pMMm: 518-70.54110
TIer ve dremM¢Cif de Wcoo be dmp dduraWxs:
RYm to Nawge AnWa Piper
11 M 8"Michael MR,proem named aorne deep nut all poeaeeacn m the uemebd remains
Pirm A"Crematory
mvnenv xuvr Is Supreme!to gone pnrea¢im OF
Me mmame to M. B. Mher Funeral Home
in ofram or n)mgiste Mai, y^,w,,www WMurry
Piper
D061Sp6i(Rw. Oa/10) "w,doweI
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