Mattison, Florence P'"G View Cemetery g Crematorium
Quaker Road
Queemsbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERALNOME: _ RkT-W. _ RETUgNTIME:
DATE B TIME REMAINS ARRIVED - -----
AT CgEMgTOfl Y; _ _ , li / Ib
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS NAME ow q
- "-�—
_.CASEp
TYPE OF CONTAINER
PLACE OF DEATH; -'- —"
ESTIMATED WEIGHT OF REMAINS S CONTpIxEq— --
PIpCEO IN HOLD:
PLACED IN REFRIGERATION;
DATE OF CREMATION
____.____
TIME STARTED: _ _,Ip MNx
- lF!.L_TIMECOMPLETED: �Q'O� AM
PLACED IN RETORT _ _7: jQ —MOVED
RETORT IT Iry WHICH REMAINS WERE CREMATED:
DETAILED REASON FOR DELAY IF REMAINS WERE CgEMgTEO MORE THAN FROM TIME OF ACCEPTED DELIVERY: HOURS
NOTE: THE CREMATION REMATION LOG -- - - — -
ALL BE BE N ED INrNE pERMANENY FILE or THE CpemgroNr.
NEFrAW YORK UivisiOn Of glvf0001
ONxorcmMErEq�Es
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or.Fry 911
Authorization for Cremation and Disposition
This AUMw ffl n Form must G Completed and signed prlarb Eallvary olnmalnatwcnmNlon.
Oaf y
:-01/6 Number: Wr
cramafry Nema: r f+n
Address: Lkea]. QuIldiffshibi &q /VIV phone:
CRE"MON IS AN IRREVERSIBLE AND FINAL PROCESS. _
liemotion O tarred out dy dacing Me t war s Nthe deceased and Me WMtlnx hiding Me whom into a mameM`Oona end Iwhom
t yansupundlnlmenso Matandnama. Theheat and mma willIncmarate and consums Mw In
w io an.nthat will Gs lefta"r unmatlon.
Follamrs cmmahon, Me uamatdry will Ikea reasonaNa a ft 0 remove all or the remains and other material from Me Common
chamber,but some minimal wit am residue will likely be If behind. The crematory Fill aepamf irmidental am foreign marl arm
He nmattu and Me intldnnM1l and Mass,mafhal as be di¢p dof as loca d by law. The aemNd nmeln Mil be r anlwlly
pulvedmd Intosm ill pier¢and VIOud Mtc a designsedd M Iner or um. Cm MW mains geonally aw pul"ftw umll no
stnpia hpmant Is rwopnia tar aukaiafl thaw.
OPENING OF ME CONTAINER
The crematory may only Oman the cement,holding Me un uamated human remains In limited ciwm m accurateness such ea IN nflrm me
identity of the damaged
Orto ensure Met OF material i¢ enclmed which might injure employees or damage Me call ancMM. if
human remains an delivered to a container which is not suitable for Overall suchae ceremonial or rental casket Me
lary will require that Me remains be moved Into a suitable wnflnH before It accepts Me remain. Theopenu ofa
con matainer m the transfer a,removal of remain Wll be conducted before a wtmess and al be done M privacy.AM dignity and rBepaR
KHRITIFI4ATION OF DECMED
Now of Oeneaid:ti _ Af l,x _M.Md sb RAlAAkl
Lam Known Addr..a:/V28 Dix A. I1 ,14A 616 / byl I?k39`
Pen of Own fM Q' . r• Awl rl m r� ' /�A1
sex Elm OF AgB-�:� DOB: OS/(7I DamoflxaM: 2 Z.O EsnmmadwmgmAA6
Dada nolcash Vcmmonew In wNN inn II MdeIIwM
roro e It jri1 r �{. l ' LL. d H lr
t OPaspgSMON
IPer¢m(a)in mnGd a MapoSNian. CIA VIC of Ilre IwYowvp)
I mar are IMdespnabd agent mine dewand designated Ina will ore nimtru ememcmed pummm he Pul
Heath Law sectbn aAt.
ORf
IM'e have no knowledge Met Me deceeeed eacmed a wwrt instrument pursuant to pubic Heats Law sectlon alot or a
dining aremmns for Me deposition of his or her ramaim and led are M la)e pere having Mackay under Puble health Law
seuon'4zol and have He night a maxi cnmahon more remand of Me deceased. fall nmtonmlto he me&caead Is as
follows:
F M
00618"4(R Wiza) Paget as
Authorization for Cremation and Disposition
(nays rmm in,us,below)
names¢ Z Deldmi 141456wt
I. A"Mon aeeiamme 'm whom pumuym to Public ImaM uw S 4201M):
2 The yurvivin0 epouse:
U. The suMvmg domestic banner.
1 Any surviving mild eighteen year;of age or order.
a. Asm"Arg "Mond
5. AWrvrving sEing ayhemn years N age or older:
S. AlaMully appointee guestarb
T, any Waymnmmigbmen years of age u'deer entldea b Share In the estate 9M who seas rkreesfln Whin to gm dW ;
e. A duly eppolmee fleumary W the¢stem:
g. ACMe Mend or mlative who has 51 a w nsmmment pwwant m Public Walth law Secdog 4201M
10. A Chief Front officer of a county on a pu bigcommispater maniacal puma t m the 5ubeabl Case Procedure Ads:
10e. Any otherpelsw who is acting on behalf of Me madmad and who Mamecused a written statement nnuent m cubic Heaton
Law 3ecWn<3011TL
`(`0)(l ALL THREE of me Mq)low4
j�IIVYa nigger am an Mat the body of Me der ddoes not"Win a Mbely,batten Pi Ni Mal mdN MMmnt,
or mm...Me device and that any such mmeMlg wore comment pre,to Me e✓awgon of Me AUNonay(on form. Mai to remove
them gem;poor to cm Mion may wag in ham,to the cnmemy and Cmmmm(ry��w""M`ORnvl.
� rwa affirm that instructions have bean given to M Icy- LtIrv.
command the rsmoml of any pmsom�l'pTrattM or ogre,long of value grouch a"parson signing bebw or my"I MemberIXMe
ag In mane Preserve. 'Y C)1 eJ l 1^em. d ri
m not meponsae We the removal of pemonal mine from the wnmmer or Mom M:remains of the aeceesee. Pa venal Items lm In the
��eomi((nln„„er or wit,I remains all IN"slrO M by dW Cremation pmues and snot ee Malignantafter nxna0on.
Vy�g(-4Me hereby auMmem Yl I )L
!!// as Cnmete the mmalrrs of the dome"
t W;OPHOAML)
uwe h...by amhorlm Me named funeral aimmor to promlee for delivery m.ad Cremallsn by an anemate
. 0¢me al necessary In the."mean of M.he and Mm m dm.. and to aeM te this rm m none Me correm name and
address ld
of each alternate creme((.
Marcel DISPO SITwx
TMPaM mho WMeaveme rammed remains of Me demauatmm MA cre+mmry'm:
Nam.: CaI rmf,r -
Agrees 66 NM Sa u& L 911 prl RODS Pbooe: tie yy9-4rx.
The oema rewire of aemas aiY be ebpoaMalwknowe:
F ALL, CeNI
g f«uryreawn N.PersonMai abw.Ones not NAM mssg on of the mabd rwrmim.
p L Ckparc/1uV m aoMvlud m give possermn0
Menamed to cat
wwl l' by delivery
in Pusan or by mystery area nWeww•.xen4 r/ rt{`4 IYIo�(I fag MAgm�
DOS 1eme4 Nm arzM Pwedms
Authorization for Cremation and Disposition
Ili Me nmwmgl
unOler`Wna lbtt NiM maybe am not claimed v.Mii 120 aayo of mmeWl.
J�1 e yt/tl �IR rn" may Malaysia&Me tmaM In
an serenade manner.Guth as by realising, ✓c.mruH
CREMATION CONTAMER RN
(n In of(he laman )
M um to be used as a mnlelner for the aemeW mandate has balm pumM hired
and adominlrea m folows: '
Me undmtetM NM it tM um is too smell to hard Me wNn ve remade, an adalllonal ngio manlier may be ui b manna
_OR-
AnummnclyetWmMaaad. INouMmWb Mat Onowniey+"MdoroMenrseprovided
ne aow CnmMMum Wp plied her CnmtlM remains In
me• `1 a toad lampeny banisher ford&'ry
This AuMomNOW Fwm was Panama by ())_` r2a executed at
A.4
and is signed by Me boards aincmr as wlimaa to Its emwaon.
Me here ranYmd a tampered may cl Nis AurhoNallon Form.
Them dividend MCMIMd below Islam the prwnM)In conbol d dbpeaXlon,who by signing this Aulho4atl Fear,a endai
W the accuracy and complelames of Information
the Informon cona to Mls Audiometer,; orm ltlo a)F and aurlas) the bregaing.
%lanesthis �Q say of f4ftsa , m r✓ ZD
IT1
„are10tb hip ( �LI
WITNESS
MCI
phi°��cz'"'
DOS.189 IRoa.M(M) Vqe 3013