Dishon, Rosemarie Pine View Cemetery g Crematorium
Quaker Roact
Queensbury, NV 12804
(518) 7454477 or (518) 745-4476
FUNERAL HOME1 __ VIIrJr4j-p1,e
- -- N� -- . RETURN TIME:
DATE R TIME REMgmS ARRIVED AT CREMATORY: M1 -
NAME OF FUNERAL DIRECTOR OR REGFUSTERED RESIDENT DELIVERING REMI'glliN$—:
NAME: ...__,____ R✓IEM
CASE N _110
it
TYPE OF CONTAINER: AS i+ t� tlx�1 —'
44
PLACE OF DEATH;
ESTIMATED WEIGHT OF REMAINS S CONTAINER___
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION; _TIME STARTED: �
TIME COMpLETEO: /PPn
PLACED IN RETORT: � I1� ��_p LW QQMM
- ___ IZ� n
RETORT p IN WHICH REMAINS WERE CREMATED: _
DETAILED REASON FOR DELAY IF REMAINS WERE THAN
CREMATE MORE FROM TIME OF ACCEPTED DELIVERY: _
NOTE: Tx[ CREMATION LOG SHALL HE RETAINED IN THE PERMANENT FILE OF THE CREMATORY,
EWYORK i)IVI510/t of DwMttww;
STpIEOF D RSIONOFCEMETERIES
°PP°NT"NM Cemeteries wao"Me1oMshow '..
Toe lAmMil!46 lE
Authorisation for Cremation and Disposition
This AurMr der Form mud IN Cwllplebe and elerren plito"Whory Ol P ne for ClMntlbn.
Date. ° "020 NumMr. �I IO
Chiral Name:Reasons Cmmm"
Address 21 Quaker Read, DwmrtWry. W 120011 pg . (51M245iaR]
CREMATION 18 AN IRRE MIBl AND FINAL PROGE88.
Cremation is fzmef out by paring the remains N the exceeds and the wnWW lacul lw riders into a cremation chamds whore
they Od mayso al to Intense head and flame 1Ne Mal and llama will bClrrMill and wnsume everytoing except Mine add m ass,
which are all ftt will M III after cmmedon.
Following cmmapon the cram army will mks reasons No enotls to remove all of the remains and other mmenal M1om Two uemation
chamber but some minimal dust and residue will likely M left Mnind. Tire oempory well ceWa@ the enlal and bRigm malanBl kern
the reman¢end Me trcidemal and bmign malarial mil M discussed Mae moment by hew. The wemekd remain¢will M theoretically
convinced mot small pietas and placed into a designated WMeimr IX um. Crwmbd mmalns generally are pui"tl unlit has
el nape.M1pml N Ncogncable as ekeleut rise.
OPENING OF THE COMP NER
The crematory may only open the container holding this urvCRm human reman¢in fumed dmum¢tarvxn such as to confirm the
identityp0edd aced or benstie that no material is entleneE wash mk]M lnryreempoyNB or damage the Memalory proWdy N
human remalna am sNIVNW in a consumer which Is not ulbbM for cnsmatlon such as Ure onlal"rental common,the
mnabry will ngulm Mar Me remains M moved Into a suxable container Mbre IreccepM to remain. The Waning No
wmainerw Me MnsMw remmal of mmame vdu lee awatwat Mroreewnrese end ads Mdone in phvep. inn agony eta reapaa.
[IDENTIFICATION OF DECINyi
Name of DemaS¢d: Ru ane Dshm V.J. «
last l(tmwn Atd'E88. N� N..i n>•, ..
Pme of DrsM.. BamhpeBarffio2e xmpM�. fir
i.WL
Sex'. ON OF Age e3 me. a111111 5 DeleaO M CPI' K*D Eemael waglrc I Lo ill
Deeatp4on N caskevwmnme in which mmalre Oil be dNivN W.
Inpamatenaumodehmanuhaure0 Nawau¢aumm Nmd am cud MCremation Co Wm
PERSON IN CONTRK OF DISPeamoN
(Pp'sUSIsfNCwnM Ol Mspmlllwe, a�a ONFNMeldldwMpf
emMHae hen MtigrWed a2em IXMe deceased deignated in swill ormilMl In¢tiumem ertculed Wnuall W Pudp
xeenn Law semi azgl.
-0R
�� Was have no Matsushita tad de e et fended ritlen executed a w inffiumem Wrsuam fiestas Pumps Health NO fie azei or a
wmanlabing directions far Me di¢paslMn of his Mr remains and IMn was this p (s) Mrind priomy under Publm NeaIM Lew
Serlem 4201 and have Me tight W1Mnae wemation 0 Me remand W the M2ased. Mylwr twnonehip to"deC WIsof
blb
Rpemeb Dishon
weplamem
DOSl8 (Rev. W15) Page 1 of
Authorization for Cremation and Disposition
preertrvam Ma wd.awl
Number 3 Dentin Survrvrg Dan
1. Fp survol mergenwril'Irp WrauarlbFWCNYM Lad Sectlan NM(3);
2 The curving douse;
I me owing doddsrgh arnye
x Mraulvivhgmiu celrteen rYn ot Area«naec
A A surrhoingMet YrerR
5. Al rvry ap Olirgeguarr years Mage or older,
S. Airy mono WmYgn Years.
r. Adulye ucary Years Of agewomer emltlM to 911Bre 1n the Ytale and who lsla�¢aoean In l&84almipNtne¢¢dews¢:
0. AeuWgrandappointed reluole who of haeetete:
9. A orage&10Mena«relative who nodaToOle ahinmergersnem vlaauarrttoaoblm Health
nn lswsewwa3recur
to. Any AreCalownwho a munry«a half of Medet2arc!all who haspurnsuarit
Arou d 0umgmes Ccun pmttEure P
10a. Ioighbon den who is acM1nB on rneltortne GereadeE all w110 nee evxNM awrMen elalemml WwerM1to PW/k Health
Iew Seaton 4301(7).
(If�Ial ALL bill of llre@Yw.wq)
�A aSLL_Ago harbor Ahm most the body or Me Ea.E SW d ec nor contain a barely barely Y} Mover Wi raaioa ova Al
or ntliYGve device and Met any soon matenals were removed eirl Me meconsn of Pis Abdominal Foml. Failure ton w
Mean Ibme Minor to cremation may Need In berm as tlw customary and crematory Yraonrol.
' S D IMle Am Mat morre oro hove been given b Regan 1. Dmemas
r yarding the removal or any YrtorW pooh or otter Ming 0view whits any anon cgrirp Mew or any family member of the
deceased wishes On preserve. Plmnw Ctanetaium
is not responsible fur Pa removal of pelsonal item fiver M9tontaimr o from Me remain dMe dared N. PenorW l4ma lBd tried
comaainnir«MN Me mnalmwlll be d""O dy Ma Nmadon proceY and YnnYMwW Am penal
*—I Wee hwaby ammeter preview Crematorium �nwev met
b cremate Me remains of Me deceased.
FINAL DISP ToN
The parson Nh an W remove Me=e tWm m d Me domed M1wn Me vemttq is,
Name: Revert I Densmore
AWrev'. t Sherman Avenue,Comah, NY 12M prome. (510)be 85
The commend members of domed will M dlapmH ofY All
Pin mmcn depenm«JrNebae Boas ndiW ItYeeea'IaedM.demand rem.Im.
PireNY Crenabnum
Rosenshine
b alMvds]to gw paYwnd
e
Me emend to Canemae Pioneer lkme, Inc. by dd,Aw/
In rwraon or by Morered real. p�ren�
Rmamene DNI.in
WS10PCf(RY. W15) mwm� Age 203
Authorization for Cremation and Disposition
llnmai Me MMnn9)
DbXke unaersdna Met it Me remains are not claimed Man 120 gays apBmetion,
Plm wLrema"um
May gdwae gait rwnaq In
anureMewde Manner, 9WJlmtry9pllenrg. ar�i
CREMATION �F J
audas!\\M'E a me ranewhei
� LV M urn to Me Made as a conWinw M and CRmaka re m has pMn persri Man Dnsmcre Fwera' Home,lx.
and le eeamlhea are ra ,Q9 } Grre
IMh uMmmna Met if Me our uha 9mellm held tMMare PMlaie] airs, an MSti Y gale c«Ilalnw"be n her MMwy.
qF
_Mumiendydpumlwog. tNYB IIMweWle melnMunl.wrNeMa«MtiYvnu provleeg
Prew Cram =
wwwwvg
will plate the has ama remains In
a gptl iemynry¢nlalrm 1M ENMry.
TH9 AWM1« ""Fomr ads Prm'MMg by HnhM I. Lbmmen was executed at
MMmre Formal Home, Inc. pxw'«mremu
SMrman Avenue. CemM, Ml 12= ornwxrum
Lore
and 15 Shed by Me In neral( lBctw as assets to he exec Won n
1=0 hav6 rech ivea a mmpIBIP]¢gy aMle AUMMzi ft Form.
Telrrear CyeMoeedtaes Were the pemnlel In control a gbpoadi who by signing NY ANMrleenon Form,argots)
to the pMtarreo d Me Infomwlen coned In M4 AUM«1 wForm and arM« s)tM f«agoing.
Mgi this Wall Ngctl ,mad
Lynn thadhorn
y F
Art
WITNESS:
Robed I. Denernore
10P10 owawmmaww �e
flmnarle DIeMn
I)CS189"(Re, M15) Plastids