Van-Amerongen, Frances Jean Pine View Cemetery g Crematorium
Quaker ROa4
Queensbury, NY 12604
(518) 745.4477 or (518) 745-4476
FUNERAL HOME:
_-........ OIpf1W
-__ _... RETURN TIME _
DATE B TIME REMgiry$ ARRIVED AT CREMATORY;
NAME OF FUNERAL DIRECTOR OR RECRISTERED RESIDENT DELIVERING REMAINS:
NAME:
LASE # _/OS
TYPE OF CONTAINER -046wP ng _
PLACE OF DEATH: 3 _ QRN '^f] Ge/ 1 I 1'-{ '
KA`t � "•._LzptDI ..CFS....RdyH.Q7._�-57118i.�
ESTIMATED WEIGHT OF REMAINS A CONTAINER I1L. Ie
PLACED IN HOLD: --
PLACED IN REFRIGERATION: _ -- --
DATE OF CREMATION: —I� '--'----
TIMESTARTED:
M A
- 'm IIII TrmECO eTEO __ )L:sO QI')
PLACED 1N RETORT -
MOVED:
-1Srr'RETORT IF IN WHICH REMAINS WERE CREMATED;
DETAILED RFgSON
FROMTIME FOR DELAY IF REMAINS WERE CREMATED MORE THAN 00 HOURS
FROM TIME ACCEPTED DELIVERY'
NOTE CREMATION
THE
L Og LL OF RETAINED INIHE FERM4NENT FILE or THE CREMATORY,
NEP WYOIRK pIVI510f1 Of Drclslota ce.Erm^�
0 U =n' ou
Abrany
Cemeteries
Authorization for Cremation and Disposition
This AUMMzoM Form must ne completed and Blamed IEd aalNery,Of remains M erxal
Dale:MwdN2020 Nu : ro�
crematory Name:Pine New Crienta m
Address Quaker Rd., Weenabury, NY 128M prom_ llr`fi
CRMAMN IS AN IRREVERSIBLE ANO aNA-PROCl
Channel Is added Out by placing Me remains Mine dewaeed and Ind aonlelrer howled Me remains;into proposal nMmEor where
they are subjected mImmnsa OR and Rome. The Morten Bame all Inchrarale and cons ume ev Ing.xc Wine and, 1,
white an all tnm will be left Offer cremal
FoRwrnainamat'✓..n me cramalory all free mechanical to remove all n1 Me remains and oddermattdm from Me pane n
chamber. Wlseme minimal dust and realdul ukeW[e led behind. The namabry WE separmn m rdental and foreign material from
the remains and Me InWentd and roMgn martini WE NO dlaFaeed alas repuim] bylaw. me cremated remains via be neemanically
Moral Imo small pass and pared into a designated comminer or um. Cremebd remain Womin are polvMvd until no
single mgmem W reaogniuele he eblwulesue.
OPENING OF THE CONTAINER
The crematory may only open the toner holding the uncremated human remand inhi cimumdantes,such no to.infim the
Wedity,of the demerved or to ensure that no material is modwtl whaA might Injure employcee or damage the oammory pro We . II
human remains are Midwest! Ina coMMnervehk0 is not suR dJ for cromium such as co enronhl praised planar,the
cmmawm will real Met the remains l Were K
lay Me
s.
call or Mc Vander or removal of remabns MII pramedical befomoverel late A suitable re aNV mend MY be0 neon pdvarynMM Methanol
eresscl.
9nih
GENT FWAT ON OF DECEASED
Name M Deaasw.Frames Jean Van NMmryen Mal Knees Mar
Lam Mil Address:3 Jon Kry Rod,Fort Edvem,NY IN28
Plain of Dead,3 Jon Kay Rd..Fat Edward,NY 12WO
see OM t7F Age..51 DDe I)i/25/1939 Data Of Oman OQJ E98ma WWght 14hlb5
Description M CaakNmmaimr In will ans er WE be delmred.
Matthews Casket Co. Cremation Case - cardboard tap, plywood bottom
PERSIONIN OMROL OF WSPOSITON
Nberviral M cinRN of di AA,,J evaill ONE Of Me Mbwupf
antl are the despnat agent of Me demesd designated in e WEor u nInstrument e: WW yauant Ed Pubic
Realm Law Section 4201.
oR.
9To have aninfrmage that be Moral drewled a ortan m.wmem pursuant m Public Heahb low Sweden 4201 a a
romamm Mlretliona for Me operation W nod rar remains and Irive are me Ramadal having proarity antler Public Heenb Lew
sun 4201 and Mve the right to currency cremation of Me remains More Meciabd. gath rremmnsnlp to the dowsed N
policies
Frances Jean Van Amefongen
DOS-1Sg8J(Rev.MJQM Feast of3
Authorization for Cremation and Disposition
... Nnwnrm2 lM xe bemwl
NrmL.r:� DegMprmrr swing.
1. A person CeaignatN in venting fragment W PANIC Health Law$mass 4201g):
2. The surviving alwuea:
23. The surviving em mi panrerl
3. Any guarani chip elgMcen yeah or age m daxl
A Aamong par
S. Aau ving aibling eighteen Have
of age or older;
6 AlewNlly appdnled guardian
L Any mmi rhavenymn of age or older emitted to share in Me mttle and what Were cicsen In relallonahip m the daceaseel
S. A duly appointed Impurity of)lie estate)
9. Atlms Mend or ml a who beg emuned a within sfatemem pursuant to Pump HwlN Lax SaCMn 4301(7);
tat, ANef most of a=my IN pa is admimsbator appointed argument b the 5umemads Court Rowtlure Ptl'.
age. My other"man whols stung on behalf of the demasW and who has executed a col en MMment Amuam to Pump Hadi
Law yvAb na401(T).
(I/nr�Ylel�ALL THREE of the feXomi
yam_ IAN
deride aMrm dal the Early at in,dezasad does ml ciat a Ma A.m"pear Pave call, raWdNe implem,
l�llfT ve tlevice and that any such madmala were removed pang to Me em mon of this AuMwm on For Failure to remove
than Rams mlm to cmnatla n may result In Mrm an the cnmatery and cmmeb paMnnel.
Me arm,that instructions have Latin given to Ua Mm S. MNM Rova�-wnr
Quahog the removal of any pasanal proper or other thing of waive wNM any proem IIprong Below Or any fri membx Of Me
damaged wimes b preserve Pine even,Crematorium
,a not reaWnsiee ter the removal W perg ea en ms Moro the mmemm or from the remains of the dx9aeed. Paraanal ume fah In Pe
container orwith the remains will b be wad Ey the c mmAlon process uM unnm b r reWevad after rnmelon.
hereby aehMU Pine Yew Crematorium
CJ/1� to cremes the remains of W dWmed.
(rare OPTIONAL)
IMe thereby authorize Me named hmral Mncbr to proNtle ter Wllvery W and creMUen by an albmam
matey.M deemed manages In the opinion of Me funeral Mari and W emend this form to provide iM wmo name and
a r"s a such altemeM1 crematory.
FINAL DISPOSITION
The peson autMd to ram"the uemeed remain of the decwsed Nam to mmalmy is:
Name.CYtiI Tturprel Obtain Inc.
Pddrem:PQBoa 67. Hudson FaXs, NY 12839 PMm. 5187474243
Tthe nemaled re ratans edecea..p nEe Missouri e.a raawa:
A {p Hm I
n W any nest the parent named above don had users,passe of Mn axnmed remains.
Pma Vbw CrarN ,m a autlprised m give me9 UWOf
Me remains to Canett Frmrel Home, Inc�vovrere dy M"
"yeaw
in r Pomn or W ieimal FMgm nVen Mrnfmgen
Pus
DOS (N
iger mi Pars 2 of
Authorization for Cremation and Disposition-
eardefIECMuow7nm
�li We uMerslena 1ta11f M¢remains am not mimed within
120 days ema4on, '
Pare Gem mnum
new diapmeahe remaneta
an in wabW mannm. McM1 as by anananna.
CMMATWN CONTA NEWRN
(t�n ONE W he mPowrng)
M um b be used as a conlaimrmr the mmmea remains has been wmnased hone
"— and is anaerobic as mimes
Am undermnd they We III too sense to hnd Me entire command remains,an addifteme mind entairer may be used he dMhwy.
OR-
��n um is net yet p+Na%e. Am understand ay nno um is purtMeea or chairman proMend
nlneY Crematcnum
wCem wall cases the e6mead homeless in
a rapid moment container for dePnry.
The A UMwlee(bn Fans was plowdel by Ce Wm S. Mi paabeuleda
rawewHx.v
Cedeton Formal Home, Inc
�ru+rnel
0 Main St, Hudson Falls, New York 128M
and is signed by Me Nnenl director as witness to lk consc n� u
IA a haw nWiwd R mmplaed baby of this AUMONsaMon Form.
The parsonis)IMntMmd MMw IYare We parmi In cone of d lspmldon,who My elpnlnp than AUMwlmdan Form, Met4e)
W Me acwacy and cm nem a Me InromuNen contained In this AUMwlaelkn Face and awhorW(s)the mmeoing.
Sipmeµla ZL a�lkrdlw 20 �
5ia i Ua✓� FnmddrmV A/ 6
4 r.. Val
Fwt fink d i
WITNESS:
Corsi S. MadM (1�
14257 rµuemrurusl 6++ nvr
Fmnbm Jinn VanA wMd¢n
Ie�✓oaM
DOS-1886f(Rau. )MZD) Feet