Ladd, Rosela L. Pine View Cemetery 8 Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745.4476
FUNERAL HOME: P&"Oc
-.-- RETURN TIME:
DATE 8 TIME REMAINS ARRIVED AT CREMATORY: - -
NAME OF FUNERAL DIRECTOR OR REGRISTEREO RESIDENT 04LIVERING REM
pper�•'=-�Y� _. -�_
NAME
----... CgSEM
_ 3
TYPE OF CONTAINER: ___ ♦ �,
PLACE OF DEATH: .-____
ESTIMATED WEIGHT OF REMAINS 8 CONTAINER_
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION:
TIME STARTED: ____ L�NM)_-1 —TIME COMPLETED: _ p
PLACED IN RETORT: S:I61 Vj IT I- ____MOVED: ___ I IO
RETORT # IN WHICH REMAINS WERE CREMATED;
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATEp pqp THAN Qa HOURS
TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SHALL of RE TMNED IN THE PERMANENT TELL Of THE CREMATOR
iOePeMwMM6YY
NEwroaic Division of DM3Ir "B'aRo
° " "'TY Cemeteries study NY °
310pM
rN.ma,�at,aro+azxe
d®mpo'
Authorimtion for Cremation and Disposition
This aNlron "Form must 0a comp"he and signed prior to aedmi of romsim for�cmatlon.
Data OW1611020 Nuitch FJJ
Chemical Neirm Plasmas CvhwMWn
�, 21 Quaker flw; p Wry NY 12904 Proer (51M]L5natt"
CREMATION IS AN IRREVERSIBLE AND FINAL PRCCFSS.
Caterwaul carred WI by,platlng Me remains of the deCBeeed and the conlamer wilding Me real into a ethanol owerther All
Mae AccuLye[led M InRnse last and flame. The MN and Mmv will Incinerate and cooaumaes2ryMlhp eadp100ieand msW
w hanaNMat Wilke Moat cmmmon.
Following syndrome the cremamry will take masonaba Malts to remove all crime remama and other matMal hen me normal
clamber, art some minimal dust and residue ant likely the kR behind The cri m it"will separate lrcldemBl all foreign male sis M1an
tram remains and the mmdeMal and foreign material vdll Ea dle{psed of recuked by lax. The emeriti nmaina vXt W muservandefly
ryNehized lnW shall pines and pMCM inbatleagNled Knhanehaum. CnwM and nsgenemllyenpolWdesdundlno
ral memmt Is tecognlaaltle:eMlatl tl M
OPENING OF THE CONTAINER
The chiral now only o{en Me cmlahuY ha lag tie lmucenalel human morl In limited circumstances, an&a[M anNm the
shortly of the deceased or to enure that T mMa is antra]which Muslim ithem emPY s A damage Me oemalal pCpM. N
h umv n niIns are Marshall In a crysta which b not sulbbb far esmstlon such as comma hill or nnhl casksl.ge
mmaWry WII segulra Matihe roT91ns b mpveM Info v sulbbM[onbineh babro tta[upb Na remvins. The Opmire Na
wnpirty oh Me tranifa ohromoval W remairevall Le¢Ml ieo [ela0 a NHMes anM will [e tloh9ln pnvacY, with dign'lly ell R¢pM.
O MIFICATION OF aB O
Nana Of OCeaed'. RMNa L. LeY MBMeI Scherer
Iat Known AdMess'. S&WastM St.(todMh. NY 1281
Place of Nunn Glans Falls Hmp Otens F"N. NY IMI
Sal OM OF Age: COB: Ot23i Oeb MOSM. �1V10 6M1nslM WayM: 20Oes
OaMpdon of a¢kNwnlaine!in xTith remains will he deliwrN.
trypymateraVmMellmanubclura) MetrMws Auma Woad all Cw MCmmadm Carol
PERSON IN CONTROL OF DISPO3ITId1
(PoScn(s)on cars l o/Nspd ran. throw ONE or Me/dlowlog)
aNJYe are 1Mt gaa agent of Me dBreesed designated in a will as WM1en InsWment vecuted punumt to Public
Health lax 3eNcn 4201.
QRR- n
M rave m knowledge twit Me decased executed a whose instrument poste l to Public Ilcoflh Iew Se[lion 4N1 Ora
MII==Irang decal for Me disces hon of his a her remains all IMe are the pAsmfs) IuvMg primily under Public Paul Lax
Section<201 all haveMe right to enhance monsoon of Me mmarns of tram beeeM Sall Mvd ip rolMMecrsetl Is es
biro w
Rceda L. ladtl
DQ&lNwf ghat =15) Page 1 of 3
Authorization for Cremation and Disposition
form lwn now refusal
Nlnwr: 3 onscreen SunMrp 51eyDaugh er
1. Aperemcerebral In suing Pool 10 fork HMM Lax S i]Oto),
]. Tn@ ounereng apoiue;
ca. The euMdng domestic Palmer.
3. My eurrol MlN eighteen yeah M age a older
A ABunil posit
S Asul nWrg eighteen years 0 age or older.
B. A tawmlly barrel guardian;
T. My pamonb)egMean years of or or older eiNtled b aKre In the estate aM SMo lNam closest In releti_r0hi0 to the Exceed:
S. A duly erNalnled tiduclary of Me entale.
S. Afor,Inert or relative who hasexeculed a wren elatemem pun used to Public Heats lax Section 0301(7);
10. Achow lieal assay of a county Or e public ad unusual apvrMd pureuem or May Secured'e Count Procedure on,
10a My May penal who is acting on Mhor of Me dressed bets MU has axeoMd aMMm embers WreuaM to Pol Heath
Isw Semlw Oxl(7).
(yp�yppj ALLyn THREE of My defwvg)
1 down helm/of Met Me budy Of Me d0.Yased does red OMrein a battery, oanery col Purer all, interstate surface,
or mdiwtlive devLU eMMMeny eucli mabdabw2'¢removed giMb Me exxM Ol Mis AUMwYatlM Form. FallumtOlemova
Mix gms on"M embedded my mua In barren b art cement and craT gpenonml.
for aMrm MaI MSWGma head bell gwn ro RWnt 1. Oontions ma
barn rg Me mmmal of any personal proPoM or Mrer thing IXv9m WNI any Person eigMng below or any worry member of the
deuwel resume to p radde, Plreviex Crematalum
ie nM rO(pnsede bMe remWel Olpersonal¢tame hum Me xnbeMrOr hen Me mmainB Mere deceaead. pmb mI M ms bMIn Me
com imr bowler Me nmalns will so cntr of by Memer aTmn Process and cannot be rebelled after cremal
11 x YWr hereby &u Oo PInal Cmmalsonum
Mcm i"nmtlna of Me dnaaaed.
f IAL DISPOSITION
11 [abroad eu mM to rewire Me=e remelm 0 the denaeYJ frown may no
Name. Robed I. Densmore
actions T Swa,an Avenue,COMM, W 12823 Pie. g515)a56aRB5
The comead remains M Mohamed fill M aepnad Of be Utl ,
Faider in family
t M any rmson Me Pamm named ayare tree ell lW pww mof Me member comedy
Po" Cremamnum huts w to of
remissness
ter moms to Darnell Furym Hme, MC now vxw Eydtltny
M palm for by reymtlad mat.
Rwe4 L. Wd
WS-1899JlRow OYIS) ntiern Prel
Authorization for Cremation an Disposition
/(femme ramwmpl
me understand same am horsy are not banned nine 1300>ys of counted.
Paevlew Cremaronum mry dsm>ea NaremYmin
an urernerema manner. >um ae W sunenng nc
CREMRTOHCORTANERNRN
fzggfW E Mare loNowlnpl
—A�An urn to be Ned an a OTfarcr for Me diamond remalm has been purcha6ed frcm Densmore F morel Hone, Ind
aMia adsorbed as id'^ - Creema Memwiel>GoingHmmeVrn
Me understand Man 0the am SM aural m hdd Me mere cremaW ranelns an season n9a demander may be uses!for defnny.
-OR
PnerhanaMpuNaved. IMle urgwtlnEtlW tlrroum la WrNaeMwotlwrvieegmAdY
Plnevidv Cremaanunn µl yJSYtln Manage remais'n
cv+n
a rgid temWary drJmainar for botany mrsn
This AUNortabn Fwnn was Pronged by Resident 1. Cmsnam nu.+mm-xvm was execanda
Oeremore Funeral Home she
wma
T Sharman sWnue, Charm fN 130II rw�somn
and is signed by Me Nrcml du%Wr as Maeen to as execution a
(miss Nva raNlved a warpleled copy of ghs AUMOrizatlon FarmThis .
b Ne accutxtY sntl w plYmeabandens n a Melon Me ded anrmtlon contend in control 0 IIn NpY Adeft0zNryon Fwmeng OW Aullsorbadon Food,arse auNwtaei Me foregoing.
A3mtl thisliondaY of w+r9N[ •.m 30 Harmless F. LWFatl L'��a— �.0. far
3s3 GggMe Ditla Pbn, Stliemcbf), NY 13e1
maomeew Mxarr
Resided I. OenemM
t09 W m� rygrrwmru rran �o�
Rwaa L IaW
very
30F18ar((Rev. W15) Ppa3a3