Poissant,Elaine T. Pine Vlew Cemetery $ Crematorium
quaker Road
Queensbury, pry 12804
(518) 745-4477 or (510) 748-4476
FUNERAL Home: ____ TUpyb,)
-.._._. _. RETURN TIME
DATE a TIME REMAINS ARRIVED AT CREMATORY: L
NAME OF IUNERq DIRECTOR ON RECRISTERFO pE510ENT DELIVERING REMAINS:
{� PAu uAjw, gp
NAME -WATN.-.�
PoxhAp CASCO .i=Z TYPE OF CONTAINER: huCQ PLACE OF DEATH: Zq /I 1 4 '+'^' J9PA.R? lsggFlLt�d�
L MMW �'f(.Ef i fj„ y t 7% 111
ESTIMATED WEIGHT OF REMAINS 8 CONTAINER ✓��"
PLACED IN HOLD:
PLACED IN REFRIGERATION;
DATE OF CREMATION _
TIME STARTED: _ - - ���- -
9cAp __TIME COMPLETED; __ �q
PEALED IN RETORT_ -
-__-14 All---- MOVES! -
RETORT II IN WHICH REMAINS WERE GtEMATED: _ ._ __A4q��L qv�� __
OEigLLEO REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN yR HOURS
FROM TIME Of ACCEPTED OCLIVERY
NOTE CREMATION LOG 5 _ . H _... . .__.___
o.W,wnmksure
NEW YORK Division of DmsIONMMMErIgnF4
srMEDF sw^e 9mwq wee
OPMVD"" Cemeteries on wB0
Ny amour
T.mgrant, i rganist
Ws.MW
Authorization for Cremation and Disposition
rideaYNp1 Fp111mW a assemblbE and s1a Marro ft w orramYm Mvamtlbn.
Dab. 04 .�.}I /]dew NmdM: /�f3
Chancery Nemx
nndrese Israeli Zl la17L
CMMATION IS 5V11RREV OLE MIND FM PROCESS.
C ddnAdn w OMW Out py award hie amene dMe Moderated and the caritlimr hilt NB nNnelM idea a connector chamber WMn
IMy ere euOgacledeiMenea MeteMneme. Txaheatandnamewin IncimrMeu conmhMM Mgt Xmreandm
Which an all tMt w0 be IM author camels
FWwnne downturn.me crematory with take reasonable Mbee to noon MI of she remains and other most tang the cremafwn
dwmber. but some minimal dust and residue will likely the left hahmd. IDa drtmaenwio vewnb incid.ntal cone loregn nmmM firm
hie answer,and Me addra ul and toreRn mareMl All low diepwed Ku hequFN by cow. no do nalM remMre will de mecxank
mrvemetl into small Memo and plane into a dteQnM conlMnx or um. cremated mnMM Sell an Wl duMlhas
Mhgb mpmml he nWW an aMm mue.
MENINOOFr ECONTMNER
Tire customary may only am,Me samurai real Me arrowheled human remains In Nmned circumstances,such cow a anMm Mm
menty of Me covered or b ensure Met and moa l as modal winch might InfuR emplocea or dunege the aemabry Ma . X
IMmen remains an delmnd In a somehow whim Is not au Malik;oar emanation such as mnmomal or nMM ae the
cmnMorywln nyuin tmttne nmMna Ir moved Iheo a sumel.wmems.e.Mn x auepb hie remelns. rha aCenma ma
aMamer or me transfer or removed of mains will be conducted desire a Arabs and We oe done In privacy wily dianlly and demand,
IM"MCATION OF DECEASED
Nameol Demeeed'.rloini r PO al MMNIS":V+ ,iOV
la"wowan :: ]7], 5insol All b(a�p.}F�g Sr ,��( NY 141
necedomm: C ram[ I rl, �,it C 2: �tn'jfl NY 121
Send OM CXF Aeft Q I DOS: I]. 107 1114 dDmm: n1 '}I /.�Ylarl EMim We M'.19LLb
Cexepcon at mske%¢N In Which amens MN Ee ONivMad.
Q+ Catl�all C0. A
PERSON IN CONTROL OF DISPOSITION
(Pemm(s) ma ddlyusiaM. Shelf ME Oft b9uWgJ
Iv can Mc Membrane!"bad Assay exeaxd Manatee in aMn MwrlMen iaMmem wmmbd puaeM to MNic
NmM law seem di
oR�
Ndihive no May gage NMNf tlasYMnieant as saner dnsae (s) a NPmlk Neale Law Os'Y11 ma
WI i2i1amid have Mtlre tohunreMhla der dast ancient and Nwe an Mepehe . broadirgpiionnder hip to Public HWNI he
sxt' ITOt and have MelghteeuMonze cremeOm NMe ameinsal NadxaeW. MYIOur Melloahlp lolly dacauedbu
Miles
Wslege+lAa'.oa(101 Paige t da
Authorization for Cremation and Disposition
tinsel me;me he hemw)
Number .3-- De yNen: tot^ —
1. A person designated in dieing gnuuess P4lc HeMYl LAW Sactian{2113);
]. TM wrvMrq spwx;
L. TM1e surviving domestic peMm;
z. My Burden chid tanner teem a age Or Mw
A AfoMvmg parent
0. A agreeing aalrm elpmem tears a age or a leer,
0. A@wfuliv eppdntec guard'oo;
T. My parsmla)elgmeen years or age or Mike enWetl to from in me OSI anawho timid Cmenm relaoomhlp to me aemae
S. A duly apmmtM(k uciary at the Centel
P. Add MeM or m i Mo has common a amen glto nl pursuant b Pudic He IHW5 on 4N1(7);
10. A chid fiaml oMmr of a wunryor a pudic ON narrator appomten Wrsuml to the 5unegae all praadun AM;
10. My parer perm war is acting on behalf of Me demafkf and wlw has accepted a writlen Mbm tWmufM m PI XeaM
law seem agm(T).
aryairALL THFEE of ma hYlnHnv
Wh MmGy affirm NT Me INCH M eer dexesa]does nM mMain a be".M mIW He mdiomcCuw LnWml,
diwMn deNw ear Nat enY auto mebnele seal removed prm'to Pe eaewfrtn a Wa AUMwbatlm Pam. FaOnam mm'n
the Hams prlarmemm onmayramuhln Wmrmma cramlaYandcr(e�m'eaypxaamN.
Iwe affirm Nm mahutAww have Wean given to eja• 1 tar�� h
7rger ,ngNe Name m any paracnelpropeMara WIN of Moff pemmagning helve aamlettiyanderof
heymeen snares to preserve, Eint jacheI
C&CH& ♦
'O rid raeynslde for Me mmmtl a pe tarn formNa mntnimr man the ma of Me ns W, Pananat Ideas left In ON
WIN Me alm WII W AeheyW by hw cmmalan p hand Ulna W neNVW a rcoemetion.
IAYmIrMY wgmMU P A2 h 1./ r aia�
rm.ww•e.w
m mmrerethe mmamaae swmw.
(MW OPTIONAq
IMv Hamby aumorW We named Nnael director to provlds for rlMl W ear emmNM by antlmmab
tIKI H deemed necessary In the opinion or Me NU ldlreclor,and to ameM Has form to proNds Ms Urnclnsma aid
and of such almmN cmma q,
mN DMPO 9 Oh
The person Lomp.hies m reUive He cmmaed r in a Me dcpsW Han the semidry in
Nairms:
tIN nauew mr.ms a aecewd xdp Ire die W and or.mlmwe
N
MbreriY rcesm IU Pmm Uned abmedo0a M1W PceOUfbnatlraammd muirre.
p ' rwx �_Lei IsaMvtxadm®rawxwamHaf
Me mmmmm Tcnir Rabodw Baca HrdMH.ry
mse
in Wrsm arwmmfde.e awl. E! g!c 7' PolffravA
DOs10gH IfLv.glk0) licadd th
Authorization for Cremation and Disposition
(azzshe Mbpw )
—to�f0r Me understand and Rose,narsoba and Mt WImil arms tan days dvvne4m,
pINlV fhst&I.n.i meYdlepme dtlemmmM
an ^(
an lneblevenN madder.auMaby vanMnp.
flUedil NI CONTAINEWRN
(Ip(pg(ONE d nre/w4owlny
M um to N usW as a consumer er mr me cromml l someone has nxn pumnan ed/mm
aM Is maw1hed as fairness'
lMe untlenbM IMI Rtlw an b has xp mlKbtlgeMn CIM1IB]demand. an MENM&rod CtlI1BInMlllsyb YME RYdNHry
OR
M um h nq yN Wmnmxd. I/We undarNM Mpro un la WadmxdamhamfeepmrnlM
p�MaYi'rU CZYt`ir� wp.w mm aemarM mNYt In
m dpm mmpamry mM9lrtrmraelrowy. ]�
cols aumonsanon Form was provide]ny IlO1'.1e1 2. �raavn wx eseylyq
Di
Tu Ai inn F.t{nl Permit
mm.wra.x.
�e�a.�.�..p era�4 �flbfl�Y laFlf
and:.Ipn.d H m.naw da.m..m ww.s m x.miawlwr.
Me hex rereivad a amplebE wpr of has Arrhom makes Farm.
The parwnW fantmmd Wear Islam IM wrxah) In control mmsWablon,arm,by$ImI pcols Aumorlx(mn Items. aWaNs)
m tM mccunry and canpNlsnxs of tlx Information conYMW In cols discrimination Form and anrNwlnfs)IM brepoNp.
SIONCmis ;01 dayof aT,f'1�a lyr .TII� .
'��tc tank �ar�f�s,lti. 7.txart—`a
kis N ;aGM ;TIf
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seems
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rpwr x�.x
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la,as.
COStSBSf iRx. ONpp) Ppa3o19
Pine View Cemetery and Crematorium
Policy for Opening the Container of a Deceased Human Being
Reference:
Laws, Rules and Regulations of the New York State Cemetery
Board relating to Cemeteries and Crematories, Section 1517 D
(1) Name of Person Authorizing Opening of Container.
PRu LVew
(2) Address of Person Authorizing Opening Container
ros 1114 AwvuE $NRgT04t1 3 trA)6S
(3) Signature of Person'Authorizing Opening Container
(4) Date of Authorization
(5) eason forCipaning Container
MOO
(6) Name of Funeral Director Opening Container
11-7i
(7) Funera9 Di� s lLc
ber
373�
(a) Name of Crematory Personnel Assisting Opening Container
N�
(9) Name of Whness to Op nin' Container
(10) Date of Opening Container
) h'gJZO
This record shall be retained in the Permanent File of the Cemetery for
inspection by authorized personnel.