Brodell, Stephen E. Pine view Cemetery & Crematorium
Quaker Road
QUeensbury, NY 12884
(518) 745-4477 or (518) 745-4476
FUNERAL HOME:
— RETURN TIME:
DATE S TIME REMAINS ARRIVED AT CREMATORY: q
NAME OF FUNERAL DIRECTOR OR RECRISTERED RESIDENT DELIVERING REMAINS-
NAME: _
- _GASEq
TYPE OF CONTAINER: n � 'Ea�l — ��-
PLACE OF DEATH: (��� -��A--,y
ESTIMATED WEIGHT OF REMAINS 8 CONTAINER_
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION: _ 1
TIME STARTED: --`
-------L� .__TIME COMPLETED: _ 3.;w
PLACED IN RETORT: -L 3'_L I ,rD —may
. 11_._—MOVED: 2-RDfr)Z,BUM
RETORT 1/ IN WHICH REMAINS WERE CREMATED: _ _— $O� .gA /T. —
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN Y—S HpLGUUgB
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION
LOG SHALL BE n[TglxeO :N THE PERMANENT FILE OF THE CREMATORY.
y1n,sill,
pepeNow MSdh
shag r K Division of DmgaxMFL EfE�iFs
STPT OF
OPPOBTuaT'. Cemeteries Audi"WashheM223wel
Tegplmm.Isr4 Oana
Authorization for Cremation and Disposition
Thle AU om Om Form mug ba COmp1 antl slgnW poor to dON Of ins Air Cr Uan.
Me: M162020 Nunbm: q3j
Qmnalwy Name, PleW Cremalaium
AMnm. 21 Quaker Roa4 Owmsbury. NY far Pival
. (618)7'R
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Qmnabon is comedy out W pool the homers of the deC m'A Neu Wnw MlEing Me remaierinb aaemetim dr Wwham
Mry are suEpdeE to intense Mat ant flame. The heal and flame will iminente ant consume"anything except Eons and mesa
which are all Wit will be left after unmarked.
Following cnmegon, Me crematory will lake reasonable aNMs to remove all doe remains and Neer material from the Gemation
consul M some minimal dust and residue will likely ad left behind. The ererralwy,will sepanle ir4itlmlal and foreign material from
the remam5 andtha irdNantalaM kreign materiel toll da diapased of esrquhed Uy lase. TheUmakd inswiiMma aniCFlly
Wbducha No small piece¢and sherd to a deeigmtel mnWWf um. CmmaW mmaina8enemllyarepulvOr un im
single Imgn Is mentimable ae"$Il ttlssue.
OPENING OF THE CONTAINER
The crematory may only Wen the Wnminer holding the un and reading ra laity In flm'IW dmmWM .such YWm mina
ear by of the sed or to ensure Met no material is aKlmed'MIIU m M night m arranged or dancing lmaem"Min
human masons aredelivered In a conmmawMch Is not suitable for cm Mion such as command or renal mxeL the
matory will regain Marine remains M moved Into a suitable cone urnerbefon H accepts the model They opening OI a
wmamer or Me maim orremWB'.of remains will beco exte"1 before a MIne55 and all as alone In Ivivacy, with denity Me refteG.
Nmne of Or:c am. SpMen E Bm]eB NMS SWd. Nmx min
Last Known Mdress. 1f55 Can at, Lakep twslm,W V818
Pace of w IM CYI St.take lumbar W t2540
Sac ®M ❑ F Age: TS DOS. wivi 8 Dole a 06a� PaMneYdWrpc lm tis
oeePlpmlmrmxauwmaMa by m remains win be delivam.
(rypematenaVmmeVmanuNMmr) Permission,Aumn WOOd and CWd W Crashan Gnlaher
p (*! NCOMROL OF OB Mglj
(1 au lsl In co'andddmpn lTlal. mi ONE d find Mani 9)
I equal are Me demgnN agent of Its de d llgn in a WW awMbn EltllmrlaatcsAYtl MFwvd to oink
Heats Lew SNLon 42M.
OR.
^la� INh have no Novel Met the dace65m executed a wrihen monument damaged by Pride Nemh lobes lion 4201 Ora
6 eMmming amcamns fry Me dSW on of his or her remains and uvre are the Pounds) having ulaMy under Male Hemb taw
Sudden OPl and have the right to auNdnse aemOon of Me remains Y the deommand Myesur memoranda ro Me dmwu is as
fallow
SIeMm E. BrWell
1M9
DOSA89FI ivv. MIS) Pge
Authorization for Cremation and Disposition
reform M1pn me Mutu l
Number.5 cameripopn: Surviving Well
1. A parson designated In wil WrsumR Or PMk HN fern sa5[n 03o1(3);
2. TM survrvmg Moore.
L. ➢vie survil domer Palmer
2, Any surviving chlid edgrMen years of age w older
•. AsurviNng parent
5. Asurverg pdmg eighteen"We of no Or media,
6. AI Older appainled guamian;
2. Ply cersmm(61 BigMren years of age or older mingled in share in lie estate and who l&are doses)in relamommep to the decea6M.
8, A duly eppgolM fill Of the esbtt.
all Adere Hand or relative year his esecal a wntlen statement pursuant to Pun4C Health Lew Section 42gl(ifl
10. A dead Rascal officer of a county or a public aNnia for appointed pursuant m Me Sungvle'a Coin Israe re Al
10a. Anyomer person who aanoting an behalf of Me deceased and who has asended a spent statement pesuval b Fud'e Health
taw Serem 4XIM.
ryptiyl ALL THREE d fine krkywas
_Il hereby,affirm Nil ma Wdy of Me deUaaed deals r`tl certain a bstlery, battery pack, power cell medical amplamt
or radiratlimdeece and Met any such m8M81s ari ram of argue Ideatida of this Au dzaslon Form. Fallummremove
Mae Items plar 10 mmeYon May mutl In barn W Me amMtory and Manuel yearraccourvid.
y( D Nh4 aMnm Mm inauClpna have been given to R~I' Dearmrrom
regarcing Me remwel of any ceranel pmpa'gy or dltt Ming 0 mom Or any Merger a¢ang Were or any family mrember of thin
mrzaaee Mauaar Pursuant °"ONen crememrimm
a may responsible for Me removal of prommat gems frown the wnMmer rr own me 2maal6aMe deceased. Fxeonsl ltem+lekm Me
miMerh�aer or wlM the remains will me dalMyed by Me cremaXon pmceea and cannot be mb Of cm n.
W�lV_Me hereby euModw Plren Craalwium
M asemah Me remains Of Me FINAI-GIMPOSpill
ne perryin,anufficinved to rerexe the aemelel nmYm Of Me deuaeedlmm they pot
xame Ramada 1. Dergm m,
7 Sherman Avenue. CM . NY l2l pCtne. (51BI S54IY[g5
me wemna remaMs a a.ream wn x mpaa d a MPas
M.iamsl wryscmelwy. (Cmnth. xr tYSY7
If M am reran the pemcn named above doer nM We pasaWa dMsaansMdmnaln.
Plreviaw cmmmonum maallsatreE m give statem tom of
day,remains W ptnvnws FunemlXwnB. lnc Ouewwm�e MdeYwry
m remain w by mail M811.
5lepun E. &pYY
+usma
pege$M3
Da51B95.1(Rry C&15)
Authorlmdon for Cremation and 01sposhbn
�/�xr�r ma mvpwlnp�
yr Win understand theta Ne remalrs are MaNmW valiant 1w Q+/s dumaticn.
%reran,Crematawal mq•6ewed dlgyradymN
an lmdnevama manner, amen as hysmtervg me7u�eo
CREAUTION CO W AINERAU RN
'/OVItlnneIO��A'Edrnn rwlon,mq
An um to be used as a cwNtrcn her IN vamN[O lemgne has been purchased from DNwrMaFulenlHpro.Nc
and is aesvlbe0 as lonows: A fA
Wh Understand that if the um band emM In Md this entire uemdM scheme, an atltllliorel rigid d'AnalWr may be uM W W&s'W
-oR
An mn la M aaI wrdneaad. IMY urdarovd mm n np unt b wmvead w ana.we pmdaed
Pmniew GamalMum HNa'<NaomMRmdruF
s�sr�f
a had ttmpmry mn W rer W distance
RIS AUNoNem Farm wee PmsWC W RMv1I. Mnamorp wu���d
pm uu pv
oenamare Funned lyre, Inc
] Sherman Avenue, Cinch, NY 13B33 nm+rraa.n
rwaara
and Is signed by the funeral director as wMaRN Ili neabm.
Whe have receNN a cwnpleled copy of this AulFonlza4on Fo m.
TM1e wnonlc)identified Mlow blare the presents)in cannot of tllaposMon,and by signing Nlc AusmrNrmr Form, a ems)
W Me accuracy and campletenesa&the Informaffon coMalrctl In gals AUNmUatlw Form and auNmhNs)Ne Fong ing.
Signed Wis Inc dryd August M 20
nub T. aim
re35Nark Other Road, Prd WW NY 124iIi) �•
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M&I® dean. MIS) PanY3013