Schempp, Donna M. Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY "12004
(5l8) 745-4477 or (510) 745-4476
FUNERAL ROME; V
_�.. YL1RQ
DATE a TIME REM RETURN TIME
gINb ARRIVED AT CR[mgipfly: 5 -NAME OF FUNERAL DIRECTOR OR RECRISTEREO RESIDENT I�IIVVERIND �REMAINS:
NAME
TYPE OF CONTAINER: - CASE ry
I'm_ _ ee
PLACE OF DEATH
: yA
W
ESTIMATED WEIGNT OF REMAINS S CONTAINER ,M
PLACED IN HOLD:
PLACED IN REFRIGERA ION: _ "-
DATE OF CREMATION
TIME STARTED: 1, _TIME CDl..
PLACED IN RETORT 7>' M (1- V
ReTORT /I IN WNIC N REMAINS _ MOVED p q n�AI1NI
WERE CREMgTEp: S. I¢�11i 1' 1
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED FROM TIME OF ACCEPTED DELIVERY: MORE TRAIN 48HOURS
_._
NOTE ATION O -_.. __..._.
ALL 2t HE T410C.0 IN THE vk lmpxkxi fRE Or THE txPmpTOPv.
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esum
EWYORN Division of ON610H OF CEMETERIO
STATE OF
°RWNM Cemeteries As =^'Albino °az3;mw
Trephine 1510146226
Authorization for Cremation and Disposition
This Antechamber Farm must be central and signed ptlw to delivery of remains for cmntlloa
Date,Seagram 22.2020 Number'. �00
Channell Name Pine Yaw Cremecy
Appear. 21 Quaker Road Queenebury,New York 12804 Phone 58-7I5MTT
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation Is cooed cot by erasing the remains of the deceased and the container holding the rernommu mto a cremator chamber where
they are subjected W intense home and flame. The hem and Some will modes M and consume everything except barks and nodal,
which are all Met will be left after refusal
Following or m rion,the memolory will take reasonable aMrh W remove all of the remains and other meWnal horn the manager
chanties but some minimal dust and all mll likely be Wfl behind. The crematory will Separate mtldandl and Megn scandal ham
the remains and the WUdenal and mratgn material will broadcast tires required by law. The aeaated remmm win he memeuealy
persuaded into small pieces and plat Into a designated container or um. CmaWmmaim9enemllyarepuNfiu umllrro
single fragment M ascribable as smiod ltissue.
OPENING OF WE CONTAINER
The aerosol may only open the mnlamer holding the un-command human remains in United urcramstancec, such as to confirm the
remark of the hawed or W ensure that no mmenm is enriched which mightinure employees or damage the channel least N
humanmmelMare dellvered in a w inerwhichis note ages for cremation Such ae renmomial or rental caeke4 Me
m2Wq will memory Mat Me remains the moved into a suitable research bran it acupb the remains. The openirg of a
COma,mr or Me Monster or removal W remains will be ecndrded before awlln6eE and all he time In anyeq,with dignity and crated.
IDENTIFICATION OF DECEASED
Name of Deceesel'. DennisM. Srliemry Mamall SeeWs'. MamM
Last"am Address Norm Ford!South(gbne Falls. New York IONIC
Place Death Okra Falls Hooped IDO Perk St Can Falls,New York 1001
sex. OM OF Ai Doe' 09-09-1952 gate Of�M W-21-2020 Estimated wat9hi: 150
Description of aaskevcrntalner in which remains will be delmrsel
Florence Casket, plywood conitgated Cardboard Container.
PERSONXCONTROLOFMSP MON
(Panama)m normal MMscoNXM. I�I f ONEWNa ordered)
amNh are the designated agent of the dismissed designated in aaiill or vn i (awarded measured pawed W Public
Health law Section Q01.
-O�R�-//yy(
/// kr INJehave no krewlef9e that the deceased argued a wrbn instmmem pursuant to Pudic Health taw Section 4201 or
yyuell ramp dimedlMs W Me battered M his a her moralfie and two are the drananls)having plorlty under Fort Health taw
Shemn 0201 and have the raga W auMcnm cemation of the remains added de¢aal MylOur Matiokshiplo Medewued ism
fmlOwm'. Donna M Schempp
DOS-18N f( ev.041 Page 1 of
Authorization for Cremation and Disposition
pnsad ram red list below)
Number'.2 Demanned'. The wrviuirp Epw».
1. A pencn de8ignmW in writing punmat b Pudic Health tow Setlir 42(I1
2. The surviving spouse.
2a. The surviving comnsc iaMer.
3. Any surviving child eighteen years of age or dErti
A. Awrviving Wrent
5. A surviving siding regrown years of age or other:
B. Alm l"ppo,Md Mandrom
T. Any (m)eigM n need of age or olderentitletl la sham in the estate and whoiaram dooms In relationship blue E are ..
S. A duly embeided fiduciary Mahe estate:
B. A claw Mend or regular who has YeWted a woman statement woodland to Public mouth Lew Sttlion 4201('N:
10. A chief huel Or 0 a wunly or a pudic addini&nW%dwiMed pursuant to the Rurmgale's Cost Praxdure Act
10a. AM other mMen who is xeng on beha8 of the dewawo ant who has associated a when statement pursuant to Pudic Heath
Lax seQun 4201 M,
()pj�p�9(pAALLL THREE a Me And")
T/ Arre hereby arm Met M body of the dewawd does not contain a banes, battery Much power All, radloatlme Implant,
orradmaove Nti and Met am such Memorableness Rmwed eform the wormle ,N lots Aatlarimam Rum. Failurebrwnove
chase items prear to cmnemn may result In harm fo Me mmM and mmatan wrsonrrat.
IMb ahrm that nst lions fuse been 0iven to Claire C. Karl r.Bx
rgaarrddiIna the removal of any onto ll pm"q u Other Ming of yabe which any Person wrong bekw or any famfy member of the
thermal wishes to combine. Pine Yaw Crem
is and responside for Me removal of personal Items tram Me candle er or ham to remains athe dewased. Pemomi ices¢ left In lM
wnMlrer or with Me semarno will be daebayed by and cmm"on pwwss and dnna the rebiesed after cmmatim
Mgt hereby sufficient Pine Vfax Cremmory ttwwr
to cnmMe M¢ remalre of Ma dawaeetl.
Ltlal OPTIONAL)
Il hereby MhaNn the named funeral director to proNde for Nllvery to and cmnatlan by an aMmab
nm=ry, of dxmed ne eery in Me addition of Me tsunami director,and te amend Nis term to provide the comer name and
addms of such aftemab crematory.
FINAL DIStPWITIOM
The pdwr minimal ill receive the uemetel remains of Me dx58sad it=the uamlpy Is
Name. M. B. Kilmer Funeral Homo
Address: lw Main Sl. South Gomm Folio, New york 12e03 pypne. 516745-8115
The Mmmd remains of de0.tl will be dspawrl Of ae blb .
If any reason the parade named abrvm does not take pawufm of the werobd nmeine,
Pine Vew Community a automated In III pomsesaidn of
m
the remains to M. B. Kilmer Fureral Hoduarm by dOWI
In person of by bas iball mail. m� Dire M. Bdwrrga
DO81888 t(Rey. MrzO) w� Petl
Authorization for Cremation and Disposition
(L ow ldbwal
zr� iMb understand tat BNe remains ere net armed within 120 clays mtremerlm,
Pi $View CAmelgy
an irtdneaeb manner, sum as 4 asanenng. a may Mariana of tat nature in
CREMATION CONTNNEWURN
(lyll eI ONE a HIS Woomm f
A(9—M um W Ee used as a mntaner As the assumed usual as teen Wrmaaee from M. B. Karl Fumal Home
and is described as mlows'.
IANe uodentand met BMe urn is we small to hold me entire vearnal remains, an additional Me whiner may be used M detwen.
-OR-
Momis MtyNWrmeEW. INNIm ndtat Bnoum Ispsm woN wprovided
Pine Vlaw Criminal will plain the uemated remains in
m++a run
a No tamFarary summer for deMvery,
This SuMoskeaon Form was gaaidW by Claire C. Simmons coda executed at
M. B. Kipper Funeral Home v.mwwwx..w
IM Main Sy.$cut Gkre Fella. New Yet 12803
am a Signed by to funeral director as will W its meddyn em
Wide bare reeved a completed copy of this Au mommit hop Form.
The persons)ManBfiee below whine Me Mnonls)in cartel of terminator.who by signing this AUMwkation Fwm,elements)
W Me accuracy and completeness of Me Information contained In MIS Sulhwlaeal Form and aWhaewtq Me forvgMrg.
zz September ad
Signed MIS my of , 2B .
Want Smartly
g NMh Road Mash Gkrm Falls. New YM 12
AmAwn
Manse
WITNESS:
Clare C. Kohl 0 a 4 4L
11au
Pnre M, sawrrgq
w..am.0
OOSI81)04(Rev. 0Irz0) Pripst3of3