Savsville, Mary Grace Pine View Cemetery $ Crematorium
Quaker Roarl
Queensbury, NV 12804
(SIB) 745-4477 or (510) 745-4476
FUNERAL ROME; _
—_-- BfiGF2__._.._.
-------_..__. RETURN TIME:
DATE B TIME REM �-AINSgRR1VEOpTCREMgTORT: ._ _P)K)A
NAME OF FUNERAL DIRECTOR OR REGRISTERED RES_ _IDENT
DELIVERING REMAINS:
NAME: _.
TYPE OF CONTAINER: _CASE N
_ .Wlry �i-�I
PLACE OF DEATH: I )D 1/.FN- s{I. v-_/� Wr� u yy-�?_ 31L6
ESTIMATED WEIGHT OF REMAINS a CONTAINER____ —�b0
PLACED IN HOLD: --
PLACED IN REFRIGERATION;
DATE OF CREMATION: _
TIME STARTED: TIME COMPLETED: �1('
PLACED IN RETORT; pp Q'0
RETORT p IN WHICH REMAINS WERE CREMATED:
—.___sl REH OI✓
FRODETM
OF AC FOR O[LELI IF REMAINS WERE CREMATED MORE THAN y8 HOURS
FROM TIME OF ACCEPTED DELIVERY-
NOTE: TRY CIUMAlION LOG SHALL BE RETAINED IN THE PERMANENT FILE OF Tryr CREMATORY.
Authorization for Cremation and Disposition achieve
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81
This AI Wndon Form Small" compiafed andsignedpnDrro delNery of ramNne Iormametlon.
Date: &SI Zo Number fqj
H
Crematory Name._ _ P'ne Vi wCm ory
Address. Quaker Road. Queensbury, New York 12804 Phone: 5181745-44TT
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation Is carried out by placing the remains of the deceased and the container holding the remains into a
cremation chamberwhere they are subjected to Intense heat and flame.The M1eIncidentaland head will Incidental and consume
eaergthing except bone and all which are all that will be left after cremation.
Following cremation, the crematory will take reasonable effort to remove an of the remains and other mrterlal from the
cremation chamber, but some minimal dust and residue will lkey be left behind The crematory will separate incidental and
foreign material from the remains and the incidental and foreign material will be disposed of as repaired by law. The
cremated remains will be mechanically pulverized into small pieces and Placed into a designated Container Or um. Cremated
malm gene ly are pulverized will rho style fregmem is remgMMMe as"i Bssue.
OPENING OF CONTAINER
The crematory may only open the container homing the unoemamd human remains In limited circumstances, such as to
confirm the ident"of the declared or to ensure that no material Is enclosed which in Am injure employees or damage
crematory property.N human mnalns we delivered In a canbinw graph Is not suitable be cre on such as amr al or
remal cal the crematory will restore that the ranalns be moved into a Estate container belae h accepts the remalu The
opening of a container Or the transfer Or removal of remains will be conducted before a witness and will be done In Privacy,
with dignity and respect.
IDENTIFICATION OF DECEASED Q
Name of Deceased: 03? 111L�. Cn_ .JZ1jOS1V�.° ��/2� ��'I Marital Slaws: brV�i'�Ca F4
Last Known Address: To �,�a S llr fmlo, h,4Y WY 13,rn/
0
Place M Death � Pt rtoS V T li 7 [
Sex: OM AF Age: 57, Doe: I0h.R/ 1461 Darepf Demo CWf;,ji EalimatmwegM: jV_Q16g
Description of¢tkel/container in which remains will be delivered-
Corrugated Cardboard Box with Plywood Starmark Model R 38808
PERSON IN CONTROL OF DISPOSITION
(Personls) in control of disposition, initlal ONE of fine following)
I am/We are the designated agent of the&ceased designated in a will or written instrument executed pursuant to Public
Heakh law Section 4201.
-OR-
I/We have no knowledge that the deceased executed a written instrument pursuant to Public Health law match 4201 or
a will containing directions for the disposition of his or her remains and )Continued next page)
�KV STtISV II.Q
oOStMN vVxNa
I am/we are the persontst having priority under Public Health Law section 6201 and have the right to amounts cremation
of the remains of the deceased. My/Wr mia6omMp to Me dxuded Is as Mlown
umisemmrhel6r Mbw)
Nbx (1 fli
um �Descnption
A person designates] in wdbng pursuam 9 Public Heats Lew radon 4201 (3)',
2 The surviving spouse;
6The surviving domestic cancer',
1 Any surroving child eghteen years of age or older',
a. A surviving parent;
S. A surviving siting eipbmen years of age or older;
S. A lawfully appointed guarchan;
T. Any school eighteen years u age or older entNedto share in Me estate also who islare closest in
relationship He the decaasei
8. A duly appointed Bdudary of the estate;
S. A does Mend or relative who has residual a Warren statement W reuan[m Public Heath Law §4201(7);
S0. A chef flsml Amrof a county or a Wblic administrator appointed pursuant to the Bunogam's Court
Procedure Act;
1d.Any other peson me is asil on behalf of Me deceaseal and "a has examples] a written statement pursuant
re Public Health Low§4201pt.
thrWALL Track of the/olommig)
I/We hereby affirm that the body 0 the deceased tices not contain a battery, battery pack power¢Il, radioactive
Implant, or radioactive device and that any such materials were removed prior to the execution of th'a Authorization Fwm.
B duns to remove these hems gbrm nanttlm may rmh In hemrto tat crematory"minatory parsmM.
Ave here by affirm that in#rurt ons have been given to d a�wcr Smn Baker1110159 ceramics the
of any Personal property or other thing of value which any Person signing below or any family member of the deceased
widestoneerve. l..ewuxmmel P'ne View Crematery not responsible for removal of personal
items from the container or from the remains or the deco sed.Personal holes Has In the container ar with Me handle;will be
destroyed 4 the cremation ampase am appears as,showed after Mmrtlon.
ro
ly-Q /We M1erebyautFor'¢e lumwrurrcmel Pine View Crematory to empire the model of
proclaimed.
FINAL OISPOSIIIOIN
The person 0uthor¢ed m receive the premabtl remains of the ceceased ham Me cremamry
Name: Baker Funeral Home Personnel
Add case ll Arabia" BheM 0ueembury New YOM 128U Phone: (51a)]61-9303
The commit remains of demainsed will be drima set of as klimers
Return to family an oe bedded
If for any reason the person named above deals cot take Possession of Me cremated remains,
stationary" Peal Yew Cliental is auMa¢ed M give possession of Me remains
Puneeawmermm ) Baker Funeral Home by delivery In Person or W registered mail.
MuN SaLx�
ocsresaawew.such) � eexaaa
(latrynefdrowma)
. IM'e understaM Mat ntne ranains am nmgaXttatl whin 120 Says of commands,
smimmy.ene) Piney Cremabry m disp ofMeremainsinanirreb'levabkmannec
sum as by scattering.
CREMATION CONTAINERNRN
aspirinpNEPFOOMIOwlna)
_M um to be uses as a container for Me cremated remains has Men purchased from Baker
Funeral Hamel and is deacnbed as fo bwis
bear understand MN if Me um is loo small to hold Me enM1m memaLLN remains, an Wdtl nal rqd container may be ul
Nrdellvery.
-OR-
-zz�yan um has not yell been purchased. VAN understand Mal d no um Is purchased or olhemise provincial
e Pine Vww Crematory will Place the cremated remains In a rigid temporary
container for delivery.
This Authorization Form was pror'Ned by vv... ivs, r.mu
was erecuted at( ,am rcme) Baker Funttal Home
)mirenl.... 11 Lafavetle Street 0ueenebury New Yak 12000 and is signed by Me Worst Mscw
as winners to as variations.
INIe have received a completed copy of Mis Australasian Form
The persons)itl edified below Ware the persons) in control ofdlsposldan, who by signing this Aullrorization
Form, attests) M the accuracy and completeness MMe information coseabled in has AUMonzatfon Form and
auMofhe(s) Me fore9uing
Bigrcdthls 1-1 Eryal 311 ate.
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20 w Ara ksdae Col 11y r111c s
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WITNESS:
a sSaa
Funeral Home Reel e01IN
IAA Sv9sv'110
oorrase+I pu.,Was rant a
notes