McWhorter, Suzanne Pine View Cemetery $ Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERALNOME; .a,.1m
- -'-- - -._._._._- RETURN TIME: _
DATE 6 TIME REMAINS ARRIVED AT CREMATORY:
NAME OF FUNERAL DIRECTOR OR REGRISTEREO RESIDENT DELI V ERINO REMAINS;
NAME: -5AZ 6✓e(L--FTK FYRP Yr _..—_----
CASE IT _
TYPE OF CONTAINER: S/(
EWa_. -"SJ�it_ Ce.Qls�
PLACE OF DEATH: ._IlLf�t1.5�. CO-.LaiE✓9..�{e.---f
ESTIMATED WEIGHT OF REMAINS g CONTAINER_
PLACED IN HOLO:
PLACED IN REFRIGERATION; LIA
DATE OF CREMATION -�---
TIME STARTED: _�� - -_ _ --
ME COMPLETED.
ITO
PLACED IN RETORT;
- ..__._.__._MOVED:
RETORTX IN WHICH REMAINSWERE CREMATED: _'!�
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN pg HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SXALL HE RETAINEO IN THE pENMANENT FILE OF THE CREMATORY.
Ismy
��11 oewXn+nta�a
SEW of Division of DmMgo ,Corm",v^�
SLaTEOF pat Cy p
OPPoRMNin Cemeteries
Ql giwirers" enter
Treasury nIffl4solow
Authorization for Cremation and Disposition
They ANbwintion Form must be completed and slim pwr W Mwyry of furtherbr mmaHon.
Dow August 28, 20M NumbBfl R)S
Cmmarory consumers V ems
Address,:21 Quaker Row,CueensWry. NY 128M Hcn: 518-7454477
CREMATNIN IS AN IRREVERMBLE AND FINAL PROCESS.
Car mtnn k carried out by played Me remains of the command and th mmeiner holding bee remains into a venation chamber whore
in"are subjected to Inane hand and Nmm. The Mat add flame will intlnnb and consume lateral B.Gpt bone and mate,
watch an all that will be NR after commerce n.
FWaMeg audit the crematory will lake reasonable eRmrtt to mmI all of bee remains and other Material hgnMecremation
chamber, but sure minimal clued and makes will likely bra left whits. Ths moon tory all separate incidental and Image actual ham
the remains and Me moMr�tal arm foreign material air u be disposed of as request by law. The cremmed remains art bra mechanical
WNaized Inn smil gems and plated Into a designated commmor or um. CnmaW nnuin Mirabelli am pulwd dealer
single fragment In recognbrele as delete Mass.
OPEX NOOFTHE CONTA NE0.
The commonly may only awn Me remember noting the decorated human demand in limited orcumstances, such we b confirm the
identify of the asserted or 0 ensure Nat no material Is enclosed each might more surpluses or damage the crematory pmwM. N
human homeless am dellarw In a container whoM1 Is not suitable far weakened such as ceremonial or overall cNnt,tat
Mabry will require Met Na remains bra mmwd Into a suitable container babas ita¢epls Its remains. The awning o e
mmmmer or me transfer or removal of remains antl be seasonal bore a wim¢5 and will he done In Phil wed Npnity and respM.
IDENTIFICATION OF DECMED
Name of Dewew'.awanre McWhorter Martel Saudis.W
Last"a"Pd8ns:10 Mm So t,Argyle, NY 12808
Raw of CeaM:10 Elm Bbwt Anne, NY 12809
sea: OM IS AMi:ad ooe:2/23/1940 Doe of Death"Sl27/2020 Ewmasd emght: 120
DesMption of inexevwneiner In Mi o remains An bra delivered.
Minimum Cremation Casket, Florence Casket Co. cardboard/pine
PER NCONTROL OF USp MON
(Pwanlsl in career ofdisposi4M. Mean ONE of"ldavnngl
t ami are Me designated agent of Me we kW Magmas m a are or%rattan Isatene s eeewted purauamw Public
HnM taw smtllm 4201,
ORS.
YMatt"moderated how no knowledge Matt" es Mi mu ra .n met mom puant to Panic Health Law aacbrn 4201 or
Wil¢nehng dimclMa err bee dkprsson W he w her remeNs and awe are me"remark)brand priorM under Public He M Law
Sstian 4201 ard have the rightto aumw royal of the mmaiee or Me demaatl. speed be ship to the dwwwed is as
rams.:
Suienrre McWhorter
DOs-18 fFiev.04120t Page I NJ
Authorization for Cremation and Disposition
graed Sao the tar momyr
Namba: 3 Dampum. Am suml chw egnteen years Of Sam or Older
t. A Parsun designated in wdtng purwam In Pubic Health Laaecmn 4201i
3. The signal ePwae:
$L This suMWnO doe Ac partner.
3. My euMnng card eighteen seem of age or Older
A Aaumaing parait
5. A purviraing aiding eighteen years of age Or older,
6. Ala lu appointed guardian:
T. Airy renonts)nphteen "am of age Or older entitled W were In Me estate and who Were dowin ml"cnadp m Me decaeed',
a. A duly appaned fiduuaryol Me estate;
9. A Clow Mend a tell who has eaeated a written statement pursuant to PUNIiC Health taw Sector 0201 p)I
10. AChef fiawl officer of a munry or a Coal Con irmagal appointed! pursuant W the Surrogates Court Proedure Acp
1(v. Any other persm who is acting on Manor W Me dxemed and who hew exacted a vrtiten statement pursuant to Pudk MwM
Lew section 4e01p6
pnmaf ALL THREE o t Ma ICAMIng)
IV A eyes narrow arm hot Me hody arms chased does M mdom a bauery, baery pau, power Cal, rediNaaNe impair,
or moral device and Mat any such matmieb ware remedial pear b Me m artiM of MIS Au6mriaa4w For1n Falluebnmom
Mew INms prior b CnmAan may nw tt In dorm b tad namalaey end wmMry pvreanrol.
-}f�NNe affirm Mel lnaMa4ons save Eeen given to Moryen WiW e���
regarding the removal of any personal gc{91y or Other MM of veWe whkh any person sgnMg be ay M any fairly member Ot tM
deceased wiate ,US preserve.
Pine Vim CremaMy
is not reasonable for the mammal of personal items"in the mnlaner urfrom Me ramams of Me tlaceaed. Pamonal6ams iM In Mo
Contelda a with M.remains will be dadcymd by the cmm ion prow"and Canna be improved after CMMWm.
* RM lNeherebyaWhoR Pine View Cremal
W rnmab bn remains of Me&co a .
(MMeICPTIONALf
IMe hereby authoriam Me named Poneral chiral W pmvlde for MGvaryW and cremation by an aM m Mr
nmdory,it domed necessary In Me opinion of the funeral diwWr, and to amend Has form to pmovldm the co Ct name and
address of BUCK alternate mmaWq.
FINAL DIS POSITION
True pawn uM Mm recess the Cremation remans of the deCwod Rom he ammaory Is'.
Name'. M.B. Kilmer Funeral Home
Mdrea: In Mein&t ,Aryyle. W 121109 prism 518E30d216
The arm ed mmairs of decaased MI be ciopCeed a as Whow :
Named A fen OfLrmc Aa ca.w
H far amry resort the Named named aWue does not leke po rim of Me crmmamd mmIng,
Pi Nw Cmmatury is subsided to give Possemim W
M W)m V
Me nmffina M MIS. 141mx Funerel Name by delivery,
in or M mgOl mail Soma makWvater
DOS1099-f(Rev 041 Page 2 03
Authorization for Cremation and Disposition
rm�palfor meaning
�f 1 M Wye understand that ff The remains are nM GaMwJ wiled 120 Made M mode n,
Pure New Qan db ry
m.wrnwm moy Elspwe dNe remsYm In
an ImeViwable manner, such as by modeling
CNEYATKIN CIX TNNENNNN
(Nxdal ONE of the/olbwln9J
An am to Ee dead as a coMelner for Me cremated shadow hard been purNe than
and I5 described as holuses
Me understand!Met nMe an is too mail d MM MB NMre damaged remains, an additional Tajo¢nYirer nay be used hr de wry.
oreQ(.! "' An dm 'a net yin µdeemed. Me uM nd Nn n ro um is pdMaemd or borrowed prwlded
Mine View Crematory will place Me command remains in
iromarinrtyl
e fast temporary weighs M deiely.
Tell AUMOMBO"Fomr was prouNm]by Mfasfun WOMs was Amused at
M.B. Kilmer Formal Nome mmaww�l
m...rmru.raM
123 Main Street N9yb,NY 12809
twi same
and Is signed by Me Nreal director as wl Is Me aoewdan..
Me have seemed a completed copy of this Authorization Form,
The answers)I4en4Md below ielare the "man(&)In control of dMposbler who by sign ng Mue AUMarierman Form,all"i
W the ucuracy and wmpleteness of Me Information cmltalnod in this AWhazatim Form and auMortuds)Me homeland.
Signed Mu 2e11, day of August 3020
flitlard McWhorter � �
yeasse
4948 bYeW avNe 40,Argyle, My 11109
whism
rmao.mnn w+ sww.
WITNESS:
Morgan WI rMrFir,m wvl �i omme
l4 % / �n w �t u
SIPBMB MCWToder
I�amar�y
COiri The,Oimad Po9e 3of3