Benjamin, Kevin N. Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12884
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: __ AvA
pfc ..SIDS-_..__.—..SIDS__ RETURN TIME-
DATE & TIME REMAINS ARRIVED AT CREMATORY: Q
_SIDE_.__ ( IRL7170
NAME OF FUNERAL DIRECTOR ORE
.q REGgI$TERO RESIDENT DELIVERING REMAINS;
NAME: _ ___ M_B_✓LAI __.BE[.—A�'n�-`Z^PJL.l_Y...._. _.__ _CASEp _ C
TYPE of CONTAINER:
PLACE OF DEATH: _ ._...__..__. .SAry_•__.__ S��jfRA --
ESTIMATED WEIGHT OF REMAINS & CONTAINER_______ ZXiL
PLACED IN HOLD:
PLACED IN REFRIGERATION; � Q7n
DATE OF CREMATION; _ i
'�:tLZe SIDS
TIME STARTED: SIDS_ 7:i0� __TIME COMPLETEO: _
PLACED IN RETORT:
RETORT 0IN WHICH REMAINS WERE CREMATED: _
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATE THAN yS HOURS
FROM TIME OF ACCEPTED DELIVERY;
NOTE: THE CREMATION LOG SMALL 0E RETAME01N THE PERMANENT FILE OF THE CREMATORY,
—J NEWYO
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Authorization for Cremation and Disposition
This Ambassador Form must be Completed and signed Shared aemwy of remains roraematmn.
Bate. Cain° Numbee 139
Cremalary Name: Pnewaw Cremakdum
Ad]re¢e: 210uaker Ross,Ouean¢bury, NY 128M Ph[m: 1518I7454477
CREMATION IS AN IxxEYEPSIaLE AND FiN P MM.
CremAon a carried M by prepare Me remains of the deUarl And The Ponbmer funding me remains Imoa stomach chamber men,
thimarecuLyMedbinlen¢elwatanb name. The beat and name ell Incinerate and consume eveMMng export bone and metal.
wkhanall Mat Mllbe IehaX cremanon.
Fdlomng on malion, We cramatorywlll lase reasonade at N remote all more remains and Met ma@dal from lee scandal
Tember, but Same minimal dust and residue will likely Ce left behind. The crematory will separate Incidental and foreign matenal from
me remains eM MB Naaetnal and foreign handfu Mll lu di¢pnsMma¢mTmred oy law. The year remains MII cemermal
pun'am4s raidsmall peas aid placedimo a de¢renahtl mmaim«un. CnmWmalnsge le anpulrMxNuMlm
alrgk M1agm t N recagnbable as ska Muue.
OPENING OF TIIE CONTAINER
The pulmonary may only open the central holding the uncmnated human remains In limited arwm¢lanw¢, a" AS Ad confirm Me
Idanbry of Me d¢aa¢etl or to endure thatch moral is mdw wall miimmiNure eT`Ioyee¢of damage Me Oema small IT
form human heat an delivered l a a con wads x not Suitable ter Wone n as comma nlal or nnal"i the
vbry AM woman Mat the remains be moved Into a an NabN will oar before N accepts Me remains. The Opening ma
mMaima Me transfer or reform m remains Mll M wMucteff before a Mne¢e and will be done In piracy,with dignity and main
IDExTIFICAMOx OF DECEASED
Name ol0.vemfld'. KbnnNEBn n Mandl Geflurs �
ten Known Mde SL /all, but, McI'T C,r:.+u�Nl llswi
PIZem OeeM. GNadal Rail Small 8page, xY f iutk
Sex'. EM OF Age'. 57 DOB ll/lVl� OaleoO Ob17R Eshm WeVA3- Igo
Oescnption Ofaskn/mmalner Inv mitre mina Milbaddry
typWryarenavmodemmanmaawrep somehow:Aurora Woad also CeMb Cremffia Component
PERill IN CONTROL OF DISPOSITION
(aemm(a1 m�ndmmrs�mm�. mmai avemmp mmwmp)
lam am Medengna ®emdMedecmadde¢®na inamll"wl"nlnstmmentewe Wpumuamto Pumm
IIaM law Seam 4201.
-09.
V�K46 Wye nave no knoMMge Mat the OerasoM prepared a owner insMment burned to Public Neann law Seaon 4201 era
A oMbimng dlRaMa far the disposulon of his«n9 remains and awe are the Penal moral priority under Paris Hall law
beaian 4201 and nave for dgrafo earnee aemanon other remains ache deasas. WMurmiaenMmmMedaw loss
blows:
Kevin eenjPoNn
DO^r1gdf(Rrt 08115) Page 1 of 3
Authorization for Cremation and Disposition
(;naapmmmexsbemw)
Number 2 Dome ion: Survival spouse
1. A tenon designated mwrmng annual m Papua N laa5eWm 6M1(3):
2 The surviving spouse'
L. no suMving domeapc pane,,
3, Any A ASurti�'ng Nis agrees"am of age by
y parent;
S. Asurl51 Win porn sughadyin or age or OlderS. Alobby
an
L Any person(s) eighteen years of age or pass SNlM m stare In the estate and ordinary postal radial p to the deceased.
B. A duty apNbAdd nduuary of the estate;
8. Adose hand or relive,who has executed a arNen atnlement partial m Rude Heats LwtieGion 0201(7),
10. A&I&front offer M a Wual or a on d¢administrator aspirl Wreuam to Me Samgete s Court Problems Act.
toss. Any other Person MO is aong on behalf of To daeasM and wM No exsdM a wri AaNvnem pursues m Public Heats
Law Seclim 4M1M
Mail ALL THREE Oft Nepal
IWe hereby affirm Mal Me body o1 the dooased does not contain a Cardin. barely pack, parom all, redlpcpve implant
a radioactive device and Mal any such materials v2s removed prior to Me eaecumn of has AWM/I n Farm. Falluwmrml
nose Ibme priors em=Wn my mean In harm m un cannel and commit Pesomod.
SB IMY afirm Mninshumom Kx bxn 9lvanm No t1. O amour
regarding its rmwal of any Oarsonel p'gerN or Mil Ming 0value Mich any man on signire balox or any family member of the
deceased wishes to pssava mraniew erenamnum
is not responsible for Me smanal of prsoMl items firm the container or from the smalN 0V9 Meral Pasonel Imes led In the
m�usical or weir the mail Sri the destroyed by Me broads Prousse ad and mnnolb MMyssd are crmedon.
musical
6 IM'e hereby auMww PmBw"emma mm
to areal me mnams of Me daaewd. m�xrm
FINAL DISP03I11011
The pecan appeared m mats Me mmX remmrm of the loss¢!hm de a6malory IS
Name: NdaN I. pa MM
A�reu. T Sherman America LmM NY 1280 Pam. (518)55a-8285
no OsmBIW NMIM mdmesM Ad be dm{.paM of as below
R „ F � rAaa lr L'7`--
IrMvd mesrn Me pemm rimed emus sae hmmlmlmamdmaMecr.mmd mmmna,
Pis mCmmatonum isadbRM to sire aaaWmnof
the rmemam Deremore wesrm Nme. Iz. gawmy
in pounds al regimsd mail.
own d min
D08-18abf(Nei. CN15) Ppe1a]
Authorization for Cremation and Disposition
� lemma rdrmrMm
IM@ undsomane that it the rei are not seemed wlmm 120 Jets olueme(tM.
Freviev CremeWnum army tlapase of firs remahnM
an ineVSvethe manner, seen p by smug R m.nwn.�mn
CREYRi COMA NERNRN
B ONE of me hYloverm
Sb An an M a Mad as a umreircr for tlg amounted remane tws Win pucMee0 man 0edmme Fumal None, lac
anObtlesmoeo as Mllmvs creg4a, it Q aht' Ae�w �
WJB UmImIBmaMM tla[ilme um ie Iw mall M IMEtlN YNrB tlemeMJ nmeira, en eMlllmel lgq VM1aiMmnOy M u»f MtlNfmry.
OR-
M Um le nd Yttgn01BBBJ. INieuMxaMM mpt llmq la gatlVeed a Wemaa pvAJM
PInNmw Cremelaium ell place me aemBM rearmed in
m•.wu.ep
a MINI mmpmomy Yemeni M tlNNBrY.
The ArMmtra Fpm win provided by RdeJ I. Dmemare was esxUbi at
oYiunwa Fureal Rome, Inc nw+rvoxwtiom
7 Shaman Away e, Canton,NY 121 mmn wvrvmv
and l0 nlgled 0y the funeral dlr4d an wgreu l0 he Baosman
IAYe Now ttcelved a cwninated ropy of this AWnaXapbn Form
The pemwnial managed Name ISMn me personisi In aOdml of dispOsaion,xAe 4 signing Mk Aumonaalmn Farm,aMyst
Wine Im urNy SW complemneu W Me Infomreapn PomrWned In Mp AUeWIWM Form and Maharani am imegdng,
Slanad Mm 1111 dsrad AJgudsf gg0 (�
KMlnn &nM1NIn 1, 1 � pW �}(jy1 caWlyl
rxrowurr. Ankw" F41 !W Z � la.mt� tZ a
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Areas
WITN :
Roan 1. Demmne
tOd10 mramsw.y u
lath Benjamin
OD Iiasg 1(New Wild) Magi