Boucher, Diane L. Pine View Cemetery 8 Crematorium
Quaker Road
Queeasbury, NY 12884
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: _. BApa- - - - ---
--___.____ RETURN TIME:
DATE A TIME REMAINS ARRIVED AT CREMATORY: ,_ _
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
NAME:
009f Q-Z 'I -----CASE 1'P
TYPE OF CONT4INER:
374_3
PLACE OF DEATH;
ESTIMATED WEIGHT OF REMAINS A CONTAINER_ _
PLACED IN HOLD; _ /IM— n(y�ny•
PLACED IN REFRIGIRATION: T
iD
OgTF OF CREMATION:
TIME STARTED: Ip:30nt, _,TIME COMPLETED;
PLACED IN RETORT:
RETORT pIN WHICH REMAINS WEREERE CREMATED; _-__$�_ II
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATEp MORE TNgN 48 RS
FROM TIME OF ACCEPTED DELIVERY;
NOTE: THE CREMATION L04 SHALL RE nEigINEO IN THE PERMANENT FILE OF THE [gEMgiORv.
ALthorizationfor Cremation and Disposition
Cal(clews,oba w ova xmawn..anue
al(snisusuz
Reveal
Thu Authorization fcml muff be cempley aadaignadpd"M "tR of m Wns Mcrematign.
Date: At it,, ST IN UNIh — OhlIIAJJIT Number '22q(n - 2(j,— PAb ) Il"
Crematory Name. Pine ViewCrerratory
Address: Quaker Road Queensbury. New York 12804 Phone'. 5161745-0677
CREMATION IS AN IRREWRNBLE AND FINAL PR0OJ
Cremation is carried out by placing the remains of the deceased and the container holding the remains into a
cremation chamber wherrithey are subjected to intense heat and Flame.The heal and flame will lndnente and wnsume
everything ptbone and meld,which are alltsar will be left Near m Won,
toI larval ng cremation, the crematory will lake reasonable efforts to re move an of the remains and other material from tha
motion chamber, but some minimal dual and residue will likely be left behind The crematory will separate Incidental and
foreign material finch the remains and the Incidental and foreign material will be disposed of as reeuirtd by law.The
cremated remains will be mechanically pulverized into small pieces and placed into a designated container or urn.CmSmma1
maim generally are pulverized!And no tingle fragment is recognizable as sMNal same.
OPENING OF CONTAINER
The crematory may only open the container holding the on cremated human remains in limited circumstances, such as to
confirm the identity of the deceased or to ensure that no material is enclosed whim might injure employees or damage
crematory property. If human remains are ddlvered in a Container whim Is pal Suisse for Cremnlon such as a teremo al or
rental beef the crtngeory will require that the mnains M moved into a suitable Conulner before It accepts Me maim. The
opening off container or the transfer or removal of remains will be Conducted before a witness and will be done in privacy,
with dignity and respell.
IDENTIFICATION OF DECERSED
Name of Deceased 1 INF I V11LIC& R Marmil Status: hujnRr FN
Last known Address: n-a'1 n fin �T qtb e091 MJjJ Kitt 12522-
PlaceofDeath: SRIVL Ai AV37AiF
Se.: OM OF age: kt-J DOB Li IIh IT Data of Death Estimated Weight: a Ilnm
Description of casket/wntainer in which remains will be delivered
Corrueated cartilegand Box with Phyarmad Starmark Model d getting
PERSON IN CONTROL OF DISPOSITION
(Personts) In Control of disposition, initial ONE of the following)
I am/We are the designated agent of the deceased designated in a will or written instrument executed pursuant to Public
Health law section 4201.
-OR-
Ali I/We have no knowledge that he deceased executed a written instrument pursuant to Public Health Law section 4201 or
a will Containing directions far the disposition of his or her remains and (Continued near page)
FLAME 1— Vd-ILICIii
abscissa+Nit.ovml awmmwwww o•erwa
y IaM we am the peremp) heving priority under i health Ow section4201 and have the right to authorise memrtmn
of the remains of the deceased. Mai relatlonselp to instrumented Is as Mlbvn:
pinsm Pram the lur 6elnwl
Number-1 oescdpdom 5 f`i'n� IahteY
A person designated in writing pN3uant W Putllic HeaNh swam 4201 (3);
2. The Surviving spouse;
L. The surviving domestic partner;
IT Any surviving child eighteen years of age or older,
A. A surviving parent',
S. A surviving sibling eighteen years of age or older;
G. A laNully appointed guar0ian',
2. Any person(s)eighteen years of age or older entitled to share in the estate and who islare closest in
relationship to the deceased;
0. A duly appointed fiduciary of the estate',
a. A dose Mend or relative who has executed a wntlen statement pursuant to Public Health Low §42g1Q)',
10. A chief fiscal officer Ma county or a public administrator appointed Pere tMto the Suaogate's COurt
Procedure Act;
1Oa.Any other person who is acing on behalf of Me deceased and who has executed a written statement pursuant
W Public HeaIM Law§421
(ipgrpfALL Tfung Of MefollowHg)
MS Alive hereby affirm that the body of the deceased does net crntain a battery,battery pack power ceq radloaarve
implant,or ra fidecons,desire and that any such materials were removed prior to the execution of this Authorization wrm.
Failure to remove Ness deems prior to cremation may result In term to the awrutory and chemistry pnsmnel.
NS I/We hereby affirm that Instructions have been given toµmwumnw l fos+la RaNem414IPJ regardingthe
removal of any personal property or other thing of value wh ch any person signing below or any family member of the deceased
wishes to preserve. Immaruvmmw not responsible for removal of personal
items from the mother or from the remalos of the deceased. Personal Items left In the container or wish themnaNs will be
destroyed by the cremation posters aM cannot he marlivved after aanatlan.
Nch lMe hereby oumorme rnemn=rv•o^"I p' Y ro cremate the remains of
thedeamosed.
FINAL D SpOS T ON
The person authored to receive the cremated remains 0 she deceased from the crematory is:
Name'.
Address: 11 1 idayethe &NO Quedurithumv New York 1781Phone: 510 T51-g303
The cremefed remains of deceased will be disposed of as f reavis
Return to family W be carried
If for any reason Me person named above does not take adsorption of the cremated remains,
mennyay,inns p'nw nwf a auNtttized W give possession of Me remains to
µvva lmme l k by delivery In person or by registered mall.
l F Yd` I i
WaYaerd rev ovaol tin rrf� Pv +2 nra
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N S IMk understand Mat if the remains are not correct wbdn 120 days of oremat'lon,
ro.*warvrwml P'ne Yew Cremamry may dispose of Me real in an inetliavade manner,
such as by scabering.
CREMATION CONTAINERNRN
I of ONEafthe/albwing)
An urn to be used as a container far Me cremated remains has been auditioned from Baker
Funeral Homes and is described as klloons
li understand that ill the um is mo small to hold Me engre promoted remains, an additional rigid container my be used
mrtlelivery.
OR
A^ um has not yet been purchased li understand that X no um is purchased or dhenyise provided Imawy
nwnel Pine Yew Cremamry will place Me cremated remains in a rigid temporary
container for delivery.
This Authorization Form was provided by annWea.unmme) ffe
was executed at usi nw is Baker Funeral do
Mmmmmewweev tl lamvette SVee Oueanabury Nex VOA 1280C and is signed by Cre funttat dredor
as wastes to its execution.
li have received a completed copy of Mis Authorial Form.
The psrsoni Identified below aware M r normal in cvnMN ofdrspos#ion, who by signing this Authorization
Form, novel to Me accuracy and comdandist of Me informal contained in Min AUMonYabon Form and
aamodzefs) Me foregoing
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WITNESS'
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Funeral Home Ran #01130
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