Allen, Herbert Pine View Cemeter
Y 8. Crematorium
Quaker Road
queensburY, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: ,yam
RETURN TIME _
GATE a TIME REMAINS ARRIVED AT CREMATORY:
NAME OF FUNERAL DIRECTOR OR RECRISTERE O RESIDENT DELIVERING REMAINS-
NAME:
CASEX _ L�I TYPE OF CONTAINER: _
PLACE OF DEATH:
RIL Nw_yFfAL_----
ESTIMATED WEIGHT OF REMAINS 8 CONTAINER
__ _ l5b I�
PLACED IN HOLD: --L�-�C
PLACED IN REFRIGERATION:
DATE OF CREMATION; �---
q� Im_
TIME STARTED:
JjpAL_�TIMECOMPLETEO:
PLACED IN RETORT: __ ja(QAd_ LIFE
"' ._—MOVED:RETORT _ _ _tf; oo�
Y IN WHICH REMAINS WERE CREMATED:
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN Ag HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG
isare
Opu emynhAare
—�NEWYORK Division of mV6wroNOFliven"NIEs
L S�jTR EOf DIVISION OF
UMe RIM
rai
OPPp(rUNITy. 99vieminymverenue
Cemeteries „a6taW,
e4MearM6226
wivemi
Authorization for Cremation and Disposition
T ISAUMonxefian Form mama completed aM.IBneE pliorto EMNery or Mmalne Iwthwes n.
once:8/29/2020 Number �gl
Characters Name Pine View Crematory
Quaker Read.Oue q.. By 128M 515.7AS r
AWress: Pere:
CREMATION IS AN IRMWMIa AND FIML PRMM.
Diameter is urren Old by plating Me remains ate deceased eN Me anreiw NOMirp the min into an eon chamber wMM
May are subjected to Intense heat and flame. The heat and flame will Incimr ads cons) ev 1"9 exup[hods ads total,
which SM alI Me Will be left after channel
Follmnn9 aematbn, the crematory all take reasonable efforts he remove all of Me remains and other mmnal from Be v m bon
chamber, hM some minimal dust and residue Will likely ce left behind. The vemeMry vnll awarme madmi and Omgn material from
the remains and the ifludental and foreign notenal hill be disposed of as reouked W law. The IXemated remains will be meTanimlry
pulverized iad amLl home and plemad,mo a designated WMalmru um. eMm.btl Mm.lm a•dsMllr ads pWwnMd uMI no
shale fragment in Mcognwble as Federallivue.
OPENING OF THE CONTMNER
The camel" may only open the designer holding the unrmmead human remains in limited dw ce W mstina,such we to nlmm Me
Idan6ty ads t bed a ensure Mat no material is eOClosN such myMlnjure employees of damage her Penncory prgrtny. If
human remains are delivered Ma condMerwmch is not suitable from cmnamt such as conern for rental wket the
emy will "and Mat Me Mmeds be moved into a suitable coYlm nr beoM mpb Nac Me remains. IDe opemng of
container or Me tMnarer or rencoved a remains win be conducted Mitre a woman and sell be now in prlvery.wNt dignity and respect.
IDENTIFICATION OF DECEASED
Herbert Allen Married
Name a Damaged Medal Stamr.
7256 Fish House Road, Galway, NV 12074
test Known fts
ptam Of Deer, Saratoga Hospital, Saratoga Springs, NY 12866
Al
Sea: OM OF Age: a= Doe. 9f30/1932 omeaoWM: B/L020 EatimaM OM. 150
Dexx tr ion a se.keuwntaimr in whin remeNs set OF aeYvwM.
McDonald basic cremation container, no interior
x NcoxTROil OF DISPOSITION
fpaW'rlal in ronba of ta os, MME uXEdMe @vwHnpl
I amAW are Me designed pent of the deceased designated M a all or r n mainstream sae CuhN purwanf M Pudic
Heads lJw Section 4201.
Ar -0RR-
.rR,A— heme have nokr lmge that the deW9aM toward a WMNn Instrument WMWM M Public Heafth Lawa ion 4201 Of
roll wnlainhq di ectima for the Miquelon of his or her remNna and year are Me TeoonM) hawing Yimity under Public Health dew
Sa 4201endhave Me NhttoautW ¢eaematWNMe Mmensdnnde asW Mywur relationship to Me deceased Mas
blew` Herbert Allen
DOS-189i(Rev. Wil5) Page f a 3
Authorization for Cremation and Disposition
bell Meanswered
1. -9 IMb understand Met slow remains are nWommed wi1M1m 120 days d crarrecon.
Poet crane ry
may d pen of the remain in
an irrational manner. wa as by scenennq. pissn are
CREMATION CONTAINEMRN
(IrvM1a ONE Poe/dhrvmes
An um b be ueW we a contains,ter Me wmaled means has been Pubasad from
and Is downbeat as blWws'
l All understand that lane um in ran amml wnold Me smile uemaed r nalna.an additional ned wntalr er may tea wall for deal
R (aoR ^
% An urn is out y&Wraased. [Aft unlenrvA Met Mnourn is pucM1a9elw NM1ewiae PmWlel
W YMw Crertelory
r�ut>rr+M will place Mewemeled remains In
a nod temporary censurer for dNaery.
Patricia Miller
The Authorization Form was pranded by was execNed at
..a,.,i
Brewer Funeral Home, Inc.
24 Cbundi let bXe -wems. W12M rn"iOX°s"°°O
and Is stirs !Mane lunwal wactur as winners W bs execual
IM1Ne nod reediest a mmpleled wpy of Nb AuNonaeYon For.
The parsanls)barrel below will Me paAOole)in Contra! of disposidors who by mining this AuMgivGon Far, small
to Me fscurel end complete of Me informal contalrad In Mae AuMonme For and authorities)tan foregoing.
Signed MN 29 dry m August . En 20
�,r tan Alter, �y�-�C'4514�—� S . r
�NE
a:
Paral
Peed Miller i�n_M.W�Ar)n�,r1t
new "ItAdraw) rn.wuaa.yvnW
12955
Herbert Allen
w•-.ra-�m
COS1e9i sons 03115) Page 3 Of
Authorization for Cremation and Disposition
paaart fmn tm nsf btixavl
Number. 3 Discussion
1. A depend 0arginaW in among PuauaM to Public HUM law Stephen 4201gef;
2. The Appeal annual
U. The rural Oaneetic partner;
a. Any solneving onto ei9heen y98B M was or olderi
4 Asurvmng parer',
9. Asurvrving sibling eighteen years of age ordeal
8. A lwAulN appaiMeo guardian
r. Any penal sell years of age or Oder Sr W to sham in the prove and who idere deae9l N rela4onarip b the dembeeetl;
0. A duty SPOMWJ fiOutlary, of Me deals,
9. A close Mel or Mail who has exanded a wrilfen statement pursuant to Public Heats Law Sol QC fij:
If AHi fir®I OMMr N a county or a pules[administrator appointed punsuaM he Me Surrogates Coal Procedure Al
102. Any beer person who b 9"on bi oil Me command and who has admitted a wrMen statement pursuant to Public Heats
Law Sermon 4201M.
l�IAU THREE aerie M4oeraal
irwa hereby affirm Me Me body or the deraaue doer not wnein a battery parody par, Rover sell. unintentional
or anal del and het any sum materials were removed enor to the eaeuem Otis AenonaeNnn Fore. Fanu e W remoea
Maraismspnorrocnmlonmay result In Iradmto Mace abry and cmnatery genera 1.
PMtle MIIIX
IM4 aMdm that matmmoma have been:span to _
o,mrw.w
regarding the rammed of any personal a�y�echat of value when any Norman wal esters or any family memlderofthe
deceased Msher b pmene,
is me personal for m ,removal of Nmonal Means"in Me conairer or them Me reewlm of Me deraarad. Pe lgems hear in ur,
mnmder or wish Me emahewill bsdes"ec! by Me margin Pfecese and ctinnObe febewd after dremgon.
Piney Chaney
If/Ie trod autom.
row++i
e estimate Me renalms of the deceased.
FINAL DISPOSITION
The pIXwn aushor m ad to defense Me managed parent of Me mreaal from Me memnory le:
Bravrer Funem Xome, lrc.
Nam
20 Chu" St, lake Wzema, NY 12M Hit
Acki Phone'.
The reread remains OF deceased sent l despaeed of as Mbxs:
returned to family
rca any reason the mrson mores Mow dose Mtake Poasassan orMe'menaled females.
Pine New Crameery
raw is awnon:ed m give posaweon0
to remains to Brewer Funeml Home, In, by delivery
owass
mail in rwwn a by ngiaered . wmw�
Hertel Allen
DOS18�f Raw, C8115) t wr�.n Paggi