Thompson, Lois A Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4478
FUNERAL HOME: _�_NR t
------ - ___ RETURN TIME: _
DATE A TIME REMAINS ARRIVED AT CREMATORY: �D(ro I')Sm
NAME OF FUNERAL DIRECTOR OR �R EE�GFUSTERED RESIDENT DELIVERING REMAINS;
NAME: gIJ _�
...___.CASE IT _�
TYPE OF CONTAINER: _mr� -. l�. ._ kARE' a E
PLACE OF DEATH: 3_�r
ESTIMATED WEIGHT OF REMAINS S CONTAINER__
PLACED IN HOLD:
PLACED IN REFRICIRATIONI
DATE OF CREMATION: fbi I za--- /I
TIME STARTED: __ �.81Al�n— TIME COMPLETED: I6 YtAh
PLACED IN RETORT; A f djl
Qptt IL
RETORT N IN WHICH REMAINS WERE CREMATED: ___sBEEL e )f) R _
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 43 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE cgemgnox L04 SHALL BE neinineo IN THE p[gmAx[vi FILE of THE dexniogv.
of
NEWVORN. Division of DmM of NeMETFl. O�s
STAiEOF ` m¢ rePi
closer
OFPoPNHIiY. Cemeteries
ne.ISIS)4Yaxxs
he pi
Authorization for Cremation and Disposition
This AU dzr on Fond must be completed and syne0 prior to eellnry of remains tar cr Won.
Da_OMOM2020 Number.
cmm=q Name, Pire mCnmWhlm
Address'. 21 Ouaker RoAl Oueembury,any 12MI plpmp l5ia)Tsbal
CREMATION IB AN IRREVERSIBLE AND FINAL PROCEDI.
Creme is carried cN W Placing The ramains of he 0.sera era and wMding they remain into a cremaptn tllamberwFRre
May we aUWy tolanse oral add ar flame. The he add flanw"Isomeone and WO mB mgMl bases and L
saki)an allget will W she able cm Oon.
Following cnema0on, the commary will Wks sommu b Isful W remove all of eye remains add other mmenal Ron Me aemol
chamber, bit some MMmaldust and reshe will likely tea left behind. Themmarynnlupere ,m, ealaMbreignmarenelfign
Me ressarry,and the x ndMldM e' mMag yUs INe mNNemw
N ry
pulvaned Iran gacee ayag M vWamwum Tbn gxryanSubletial u no
at note aM e reenwle.s Swi
mw.
OPENING OF THE CONTAINEA
Re demerory piny only Wen Me mainer hM]mg NB uncremala]human remains In limited Circumtlm shou as to mnfirm Me
human
INtlrede seedrt Ina mAMmr hichgerclwM wMU corrosion
or Crematbryrt the
M1uanq sellbandNNxed Inaconz her which Postage
forcrnmaednre pch as,ceremonialais. Thed casket this
awryrM repoln MetmoamelmbsandlessasuBa bleed a wmnbefore itROp6 are MICY w theree and INa
mteiner or Me tranahr or removal MremeinvAll tea WMucred beyond a wtness aria MII ce bane In p^s'aq, win dlgrtity and reapedIDENTIFICKTOW OF DECEASED
Name of ce2ased: Las A Thdmpmr M wStatus,
Last Known AdL Anne Sit M.Ca ,NY 1=
Plains of Damon mountpwnmN Yp PSW
sae. Dm OF Age: 61 OOB. ta20iw min of exam. 06M1s12020 F.bmabd NBaK
D dYpmn NCe wIN unarm wniN remaire we be"nua M.
(ry matenallmMWmenuf W) mahhewe AuaaW imp CaflWrd Crearlon Consumer
OF M4Po9mON
(Pens(¢)in CmbNMMpWmfis, initial VNE mbn M 9)
I aNWe as,the designated agent of the dozased deigrmted in a vale an written lMttument us, OW purpose to Public
Health law secdCn 0201.
-0R-
�T IMb hNe no knGMM Met the dosed ettad a written iarrumam Moslem to Public NeM LAS Mormon 4201 era
mo UwlwmW din $for Me dispvi4on M we a her rename and lays,are tM perwn(s)momg Mmity under Public Healey Lary
Cwfkn O2ot add Nre tM ngMm eulhmze vema5on INtl'e resins mtle dossed. MYIDur Mabomlrlp mtledeuasetl Is ea
an:
Lue A. Tramps,¢
DoSlP f(Ral W15) Page 1 of
Authorization for Cremation and Disposition
dnsertmm�Me lklMb J
Number 2 taboottion: The wrvivirq swuse
1. A pesm Oesigmft in mitiiq parvam to Pudic HWNbew Sxdm 4A1(3),
2. lHe wNmng smuw:
U. lHe among Eomesi paMer.
3. Any wMuiy chid eigaineen years of a"a offer;
I. Asuntang parent
S. A surviving halrcg eigamen yeas W age or oncer,
B. A lawM1illy,appametl guarden;
T. Any pereme) eigmeen theory of age of been mand he there In Na el any who were dmeM In MnMo ip to the EmeaeC:
S. A due Mocimetl fiduaary 01 Me inne'.
F. Aobse Mend or restive who has eawalm a written Neodesha Wradenl m Pudic H law Seclan 42011T)I
10, A chadfswl offit of a wunry by e Wde a inbMor Operated purcuar2 to the Suregate s CwN ProxCure PON
10. Any Other person are is adeng an EMaNIX Me 06mased and who has exacNed a written eelemem pvrwam M busk HeI
law Saccon 4201(7).
(InnddidIALL THREE gone/dloxlrg)
r Me hereby than Met the bevy of Me dewy does W Content a alder'. edtlary pack, power call, raYoacfive Im(IerM1
or eMpctive dalew and"t any such mNeneb were remw9d grip W Me"Yoution of Nis Aurl Hz O Form. Failure No remove
M// Isms prior W crmn m may mutt In harm Wtlw cramsery and assonant pareonml.
1 MleaMam MBtirm4uc40N revs Lean gran W Ramt. Oenemore um
obsessing Me removal of any erebnal pcwMwoNer MIN ofvaeewhich any Mrson span ing o&ot'many emlly memoer of the
wmftyd wilts to preaeM. PinevlW Cremalonum
is not restorable to Ne emoWl of p al hems hmi thiconeiner or from the Others More deceeWd. PerwrYl llama YaIraW
conhlrcr M wIM Me remains will oe dXlNyad oy Me cremmlon proUea and cannot be rethevad after cemanion.
Me hmeby almorW Pinmea Cmmammm F v
(( W onnwe Me rsmalm W Me Mrraad.
F NAL O BPOSITION
The pereon awthestand W chyme Me oemaed mmaiM store dxaved M1Petlw vBinBlory e:
Name: Robert 1. Cenemme
Acdress. ] Sharman Avenue, Cca mh, NY 13822 ppww: (518)95M1B3115
The gemmed remand of Miami will be d'upeNd a as N WA S'.
R � lk -1, 1&1 Lt, b4
If Mr am eaeon tfapemm pa wNMe command rnntM
Pmeviex CWmdmmm is.mWed a Wewneaalmdt
m . w
the remains to EA9n114r°Funer9 Hwne. lw n..wxvexaw b/dlvely
in person or regislared mall.
Low AT mp
W8.11me-f(Raw W15) u� PaI
Authorization for Cremation and Disposition
✓nnmafdm statementse 22T lMp undersYra tlbt It cm remins are na ammel wash 120 days of Chanhassen
passamv Caematodum halt aslraM a"remBV9m
an mean"" ami aw SS dy scanenay. wc.'nl
ATNIN Ct»nuNEMIUM
CNEIXMe M1+IlwnlgJ ZAn uan to W cam as a comei rer as the cramand Rhishe has Rican P�ad�fa5ed han reesmon Fastness Items Inc
W is dessnamed am Raises
ante mvbMand thi the um is tw aural b had the ands aNreW Rhmsm.an abaci ngY Minster mar W aW M daivsay
on-
nn Um m narat inaenaW. Bore amaYumni.IJmun la waalsa=d aon.avda.woWaed
Plre "Cremetonum OR paces peoammel ancient in
a Nld temwmry container har assets m�
This A cornalli Form wa4 mounds]ry RMaI1. D9nam ores aucultl et
x+rs�a
Cenamore FUrnitl Horns, liw.
I=
7 StanchestStanchestAVmue.CwMh NV n..i.✓w+w�.�
and is&I Ey Na Nneml director as wlm»s In is Whicew��u
INYe has,raelNd a mm p aYd copy of his AuMorkstlon FormThey .
she accufracydand camplabneus III in,lnfomsareas cassamntl In isIdom in8 utlmrbatlm Form d aoMomem)the temgo�psl
SIBnY davit AWUM
an IDp
al N
Merk R.TMmpean V Z K ?
rynmww�a Imie
sees, &i.CcdrM.NV 120Y1
mawiromidmiss seem,
WITI'li
Rated I. Devi
rm e'nxnnnM wsry
1C010
Ic4A Thompxwl
srwo.W
Ppa]M3
DOS1895-fatev. MI R)