Smith, Roger Pine View Cemetery & Crematorium
Quaker Road
Queensbury, Ny 12864
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: . __- f"EZ
--.._._.. RETURN TIME:
DATE B TIME REMAINS ARRIVED AT CREMATORY: _ N� ��
NAME OF FUNERAL DIRECTOR UA tip f" -
O OR REGR�IpSyT�EREO RESIDENT DELIVERING REMAINS:
NAME --._l"Mlb_ SLwJN -.
TYPE OF CONTAINER: __
PLACE OF DEATH:
TU l)
ESTIMATED WEIGHT OF REMAINS S CONTAINERS__
PLACED IN HOLD: ��
PLACED IN REFRIGERATION:
DATE OF CREMATION; -- ��� ---'
TIME STARTED: _ / IS, 4t7 TIME cOMPLEra
PLACED IN RETORT )q5'/m —'
—MOVED:
RETORT # IN WHICH REMAINS WERE CREMATED: __ g 'd A(1 . OMpLl ijy
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY
NOTE: THE CRCMATJON LOG svM.L OR RETAtME0Iry THE PERMANENT FILE OF THE CREMATORY.
Ni N Into
Department a sales
KEWYORK Division of arvINONOFCMw ES
OPpORT117 Cemeteries e9 ooneverIM"^over"`
,grow NY 1223w011
real failt
,were,were,
Authorization for Cremation and Disposition
This auNorin Form must be completed and signed prior to di of rzmame Far cremation.
One September 1, 2020 Number Iq
Crematory Name Pine Yew Crematory
PDdnu.. 21 OueW Rwtl OueeMbury,New Ywk 12000 Prime. 5111-748-4417
CREW N IS AN IRREVERSIBLE AND FINAL PROCESS.
Character Is earrb] old Cry placing the remains o(the dewaEed area Me container holding the remains into a vN on Chamber wtmre
Icyeresubpctedtoir wnedaMTO . TM beat mad flame Will Insurance and consume ew Ming exampl bane and minimal
which an ell Mat will Me Ito after Minima n.
FdkMng uematim, the mmMorywill bake reesonade signs t0 renose all Nose remains and other material from the Cremation
Member bin some minimal dust and wereas will line be led hMMd The ttearna ill separate moderated and Mogn mNenel from
Me remains and the screamed and Ri marginal All be disposed a as required by law. The Cremation nmeina will be mechanlulry
puNrtkM icon small p'eces and dacrd into a designated anbainerm um. Cmmowd m Wna generally an pulvvtrad ungl na
single fragment b rwUognUable As ebl W I gxue.
OPENING OF THE CONTNNER
The cannatay may may open the consumer holding the un-aarreled human remains In limited d rcurnmences. suM as to¢nNm the
kentity of the N aed a to ensure that no material is samenr when rundamryre employaca or damage the aemabry propedy. H
human remains an del"Ned In a emdiner which in nice suitable for channel such as cX onhl or real ooxet the
technology will will Pat tlw mmaine be moved into a sudtabde conbainwb om itacwpb Me mmains. Theopm,ing da
waineror thetransfera removal of remains will be Conducted NMm,a wiNeab and will be Summer pnescry wM dgnity and respH.
GENT F CAT IN OF DECEASED
Name M DeceaeM'
Roger Smith Meal Slate: MaMW
Last Known Address 20 Rivervlex St,Apr B 105 South Glens Falls. New Ywk 12803
Place of Death: Glens Falls HospBal 100 Pees St. Glens Falls, New Ypk 12801
se.: Is M OF Age:63 Doe' 07-02-1957 Date 00I 08- a 2020 Estimated weight Y50
Dwbsmwn of oNeVa turner in whim remains All be dedwered.
Florence Casket, plywood corrugated cardboard container.
PEaeox xCONT 01 OF DISPOSITION
fReratmfNPmnrMdaapPaleM, �oNEdme 7aww+ngl
I covWe are Pe triggered amid ltM decreased designated In a will Owner iromment executed Nno tto PUNIC
Heatllt baw Section 0201.
0RA-
WJe have 00 krmwlMge that the dexaaed exerted acanteen instrument pursuant PUNIC HeMP Law Section 4201 or a
All contained direGms for Pe dispomon d his or her remains and IMv are Pe Partner) having Pol under Public Health Lae
SeMan Rol and hmethengMtoau oneeuw MonoftMmmamsdtMdewased. Wy urmlauomhiPto Pe Manedisas
Remains:
Roger Smith
DOS-1 thil tow, 0420) Page 1 of 3
Authorization for Cremation and Disposition
(Indust them the NO below)
Number 2 De¢mpton: This aurvving membil .
1. A person oeaignated in writing pursuant b,Pudic HeaBF Lew Swmyn 4WI(3).
2. The surviving spouse;
22. Fee ffirmeng domestic partner',
x Any surviving Miw eghM n years W age or alder.
l Asuriiving pareMl
S. A surviving with ng eighteen years of age or All
S. A lawfully appointed lowlands;
]. Any per¢onla) eighteen years of age or drier entitled to share In lM estate and who i was cbse¢I in morn mop W the dePoeNd;
8. A duly appointed Pouclary of the estate)
9. Adean thi or relative who has executed a w n moment Wrsuant to Pudic Helh Law SedpM201 On
up. A duet fisnl officer of a county or a public administrator appointed gnrsusrat to the 5 urrrgNeb Lout procedure Ad:
Ill. Am Other pencon who is acting M behalf of the deaa¢ed and who has executed a written stMl OM purwanl to Public Heads
Law Petllw 4201(7).
((epl ALL THREE Or the(Mowing)
IMb he affirm Nat this body 0 the mkvmed does net confron a ba0ery, memory patlt amew cell, MdM ive hngard.
or redlwdiva dNira and Nat any Such meMridiwen removed p WNe execWon of this AUMWlaatlm Form Fallum WA 0"
Malawi Ibms prim W cremelion MAY Rsuty in harm W Me cm oWry and customary MMMMl.
_ IrNe efirm lam instruments hne been aims to claim C. Korwpka umao�.xw
regarding Me remomal of any Personal property or Other M'mg W vM a which am wram argued mNew or any Kmuy member ad Me
deceaud washer,W preserve. Pi"a anew crematory
ns not recpdnaige artM removal of peremal item from ids Mnlalnermhom the remains ollM dema¢ad. PemonallWms NKIn1M
o„h�rner°f colds Ne nmalne Mll pe deaboyed my Me cremaion prw.aea.nd wn"ol lu reMevW aver crmmado".
LY vxa nmrebvaumova Pine mew cremator
wn.vew acme Ne mmain of the MC d.
I�OPTIONAL)
IHq herby aNharies the named funeral dlracar a provide bar delivery to and cr abon by an aMamate
mawry rftleemed nerveri in Me opinion after;funeral director,and to amend this arm W provide Me comet natound
address of such alternate CnmaWO,
FINAL DISPoKgr ON
The Korean arranged W remi d the=mWM remains d the deceasad from tM aemeary Is'.
Name'. M. B. Kilmer Funeral Home
Ad3esm IM Main SL SouN Glens Falls, New Yom 12803 Phan 518-745-0118
The mmatM romans of d W will be disposed 0 as MW
RNsaM to hie xf N Cindy 8mM
KM aryr Me parsn named above Mes net take pcus¢im of to aema reran.
Plan V'rew Cremebry is auNaNM W give ppwww on of
o.wmmw
ttalkmm min to M. B. shown Funeral memo my defrvery
In pdam or tr/ngiaerM had. w RsxinuN
Pwnum.+a
DOS-18N TRev. 04I10) PBpB2 W3
Authorization for Cremation and Disposition
(Irtifial(Irdfial fang)
Uwe mneettrnamad fine remanear net aaimea wlmm tgg days ordeeaagon.
Pine Video Career" may disease of Me remans in
»nN
en n.eme.able manner. arm as by sudedng.
CREMATION CONTAINERNPN
(bbba ONEWIhe/dbwirg)
An um to be read as a canleinerlw Nw demanded remains has bean pumrasee from M. B. Kibler Frnerm Honda
add is deaanbed m formed,
INJe Unfetterr ti ed that the we or too sme ad Wit it Me wnm dntal e d mama.an aYmonal read container ma l y by mi lw de'wery.
oR- _ /
/�y/" Mlm�is �tyMarrmewd. Ire undemMlw mMOwum Wputcnaw or amended provided
Pine View Crematory will pace Me cremated awards In
asm om.nw
a Oral tdnpanry container N deltrery.
The AUMmmfion Form was provided W Clam C. lionesses w was emended at
W B. order Fureml Home
invem
1 W Main Sit Sw@(i Falls. Know York 11803
and is signed by the fWey direct"as waned,an Mexeaion,
Me have remrved a dempm@tl easy M this AUMorhallon Form.
The ca Identified beircraw s n of u ) )
W Me accuracy and defenses of Me Informalloncwrted In MRUMOHmtion Frm antlaumo (v the MMOOI"9.
Signed this 1 day a Bepbmber 0
Cindy Smith
30 Riva nd"Sit.AM B 10 S"dh Glens Falk, New York 12803
MT ns:
G&re C. NmxpMa
cow Me.auaw..i
or=
RWer Smith
DOS-18N f Mmv.01120) Page 3IX 3