Green, Kenneth A Piee View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518( 745-4476
FUNERAL NOME:
RETURN TIME:
DATE 8 TIME REMAINS ARRIVED AT CREMATORY: fOq-•�Q _ _ ��/_LNF�
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIpeRT p1 FRINO REMAINS:
NAME: !t�c' _JfGF.J.
Cq SEp
TYPE Of CONTAINER
< '/ Jve qWd fNf�m� �WDe--�CO.y(r/rff PLACE OF DEATH:
ESTIMATED WEIGHT OF REMAINS 8 CONTAINER I7
PLACED IN HOLD:
PLACED IN REFRIGERpT10N: __
DATE OF CREMATION
TIME STggTED: _ py.yy -�-
_ �cl l l J E PLACED IN RETORT, �y
S_Y6 _.MOVOG T I RETORT /I IN WHICH REMAINS WERE CREMATED:
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 4p HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THEc REMATION LOG
L BE RETAINED Nine ANIMANENT FILE Or THE [xEmnTonv.
New
O.wr taFsm.
_J NEWYOMY Division eie Dlvaleox0FCEM�RIn6
STRTEOi mmerce RIM
OPPo0.TVNIiG CEff1Et@riES
leAlmoelMu4sualR
wwwwwromew
Authorization for Cremation and Disposition
This AU WzI on Form most has complNae and sip prior se malwry of remains Am Cremation.
Ore: 082]fdl]0 Nana. goV
Cartel Nama: Rmrax Cr "um
AWress 210uaW Risen,Que urv. NY 1220it Fwas iISIR745rM]]
CREMATION IS All IRREVERSIBLE AND FINAL PROCESS.
Cram slim is meet rR of pecan lM Remains of lea h see and tla Wode"ar lw4Srq the remains Fria a samurai Member
mereresueµH Wirenaemearand Mme. The medical garlwwill ircmmW and arnuma ev ingruo New and meY1.
which areall that will be Wall morn n.
FdloWng comedown Me vemaWy Wit Else reasonable aflom W remove all of the remains con oux mr cal from the cremation
chamner hrawne minimal dual and undue ulll likely lee left behind Tla oemrtorv'mIl seperaR Intidenll aM kreign malenal hpn
the remains around loco al and conic.canceler War he aepoeedras regmred W am meaemaMremaiwwlicemOMBnlaly
p rem ed iris small came and passed! Mor a despnabdx Wm um Cr wmnalm Elemen F an puleelemd audit re,
mingto hapmenm Is rNOS WAsa Eli unw.
OPENxO OF THE Cd MKR
The Oemakry may only Open Me oMElim holding the uRPemree human moral in Monson circumstar2s such as to con"the
human mnal of Thad m are dNivared In carcrej or be whers,orrnerwhoh Ist nor mrsternal is not�Mi fw hisch ought
mehow
Mn such Am uR dal
mormal or miI Male Mer- H
mnmsbry will reap at Me refrains be merW Into a suitable candidate Mme it mcmf the mine no. The opening of a
Orchards or Me transfer or wen of remain rill W Wnshoof beble a Mm6s and All be done In uni wnm alsoOf BM respect
IDENTIFICATION OF DECEASED
Namz of Oemard: Kr� 4Either Mental SwjR MaMed
tan Known Address; C,r. .LA NY a
PIaw N Dow Ssa'uT Hw , Sa smi fly
Sam
ME OF Aga: 6r DOB: Ma 115s DmdD lffi]/t020 F WegIM1 )�q �
De oon WwlrN inerm MMrt out
uce edlwaV.
(yptlmatenallmachermnufa@rrer) MaOrwne AuroraW and Cars MCmm C"lwr
N pER8O N CONTROL OF OMMMIQN
(PEN IS)
in OWMa a ms wcfi ,,flat ONE or Me bhwing)
IamuYe am Me amounted agst W the emerged dKlgr in a WA awubnINtryment mw%wd pursuant to Public
Hollh lbw Rachel Heat
OR
— Ivx care no lmodnadeematmaa sae a*earedewomen mewmer pllrwam to vaelaa Hddnn new Suction azot ors
sell coMalmrp directions her thedspasNm of he or her remame and lMe are to power rasing Fort uNer Pont H®Mtaw
SrlcEm i]Ot and have Me rot W auuanre a aw of ua remains of Me decease]. MYIOur mlNoneMp N the rlEeseee Is es
n Mei
I(enwN Green
DOS-Al(Rey, =15) Paget of
Authorization for Cremation and Disposition
(maart rem me nameaw)
Notation 2 Description: Surviving Warned
1. A pxun neeienateOm share purwent no Pik XatlN lav seMm 4201(3):
I The Narrow down.
as. The survinng 0omer manner;
1 Arvy moving Wild eighteen years of We or older
A Asurnving parent
S. A wrvaing sell eigMren yearn of age or older;
B. A laMully appointed guardian;
T. any parental tighten years of We or Now eMnlm to share in der estate arm mmo Were defeat In relationship an for deae9W,
B. A Wly apgimW(idualery of he estate
S. A case Mend Or reative alw has anWlW a vnnm statement pureuent b Public Heats taw Season Q01(])I
10. Athat feral ofi¢r of aammory or a pudic admiMWatw arealnted Wrwant to me Surrogte a Court Procedure Act
lase. My either cermn she is acting an Nmdr of fM WwnW and tow has marNW a whom amended µrsuaM to Pi Heaton
lnw9easoM2010L
� Wit!HREEame fdloxmgf
�i IrNe huey Or rat that Me body of the M®aead aces nM¢ntam a hmay, hadery pack power ren. ad"Where Im dam.
IX reGCandvedmw and that mysutr materials away,hmoved pnorto Me nemtim of this Aumod mFoml. Falluetammove
man ft�m after W answe n may result in harm b Me chamatay and cnmmry ptamned.
X�sever afire Nat imN m haver exam 0lwnm RLL 1. DalmaB um
regarding the manaml of any paean paepeTy m ama Hirt INVB4e item any parsed winning other or any man Or memMr of Me
derXaeW anyone to preserve. Pirieaiew GremaNnum
is hot resporaibk tar Me removal of[ersaed Items man the condemer or mom the remain of Mr,de 8 P lRmma NR 1n tlM
c me day tom mB ranalm wall has tr" dM Mecx m prawn most unrM b redWed affix, n.
�mVe MBty aNBMn Pimaiwv Crenabnum
to Materials May r im a MadxYaad.
FN MSMSaMN
The That audmilmed Nr w they Cremation rartim N the deaewd tom Me ami Nle:
Name: Rout 1. Mnsmare
Addrem, T Shaman Avenue, Caine. NY 11523 Plate. (518)firtai
The asserted ranans of depaaBW MII be dip N SIR Ug .
Re omed tome mouse
If fa any reason the parson Need Rahal di rn WB moan&m any tlMnaled ame'W,
Pimmemmtonum gaopvi wgwpssm d
Me emaim m Densmore FUn Hann, IM Eydemary
in pawl a by Rgste'W trstl. awawmxaa
ItmmN Gran
aaaaa�
OP41N61(Res. =15) Pact W3
Authorizadon for Crernatlon and Disposidon
I��m I nmi)
urgertdM TB1iIVa rB'riane art mltleimalwWn 130 Cya M«emaliwi,
PInBVNw LRmalcnum QI Ilse RmynBip
an ureNeveEle mviner, BUM as b/amtlenrg. sum✓wrnl mry Yu¢eo
CREMATION CONIAIXEWRN
II «Mesninno )
M umla Oa ueetlue¢nWmrMtlie«emeMf n and is eea remelralwYl—w[,Cn WrMssE hen Dmem«e Fureral Nome. be ',
mnM as bIIgK: �riu r.-..."� G(n �:rynr� -A-li
W underslmM Rise It MB Um k iw mull W hM Neei memekd mmyns,an adENTBI Val anbirermay be used Son carriers
.
-OR
M urn Is M net WNUW. IAMB understand Mat if no um is wMows or adamantine provided
Pllismal CRmTgium vnII FAeSNB«emdM remains In
a rgld tempcnry¢nlelrn brEWvery wmaae�n
T is AUMarhadm Far apron b RMmI I. D«Wme and eaeWbd at
Fue+uw.n..n
Demmrort Funeral X«ne, Inc
7 SMnman Avenue, CodNb, Nr 12= Owaxvnwvr
and is elgned by lne funeral dretl«asannew to ih eaea0on��g
Ii nave m ue sed a can geted mpy 0 tiv,¢Au1M1wlBatlon Form
Time per mis)ItlantlMd below Wan tla psnani in control of dbpositlonwno W Blgni rd MIS Ammodradon Farm,admi
W"Mission"and wmpMlarwes of"IMpn n ceMeMM In Mk Bull IlBatlon Form and auNWpgtM rorerylnp.
algmtl m der or AudiI ]Om
Christmas
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