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Dumas Jr., Clarence J Pine View Cemetery g Crematorium Quaker Road Queensbury, NY 12804 (516) 745-4477 or (516) 745,4476 FUNERAL HOME: RETURN TIME: DATE B TIME REMAINS ARRIV tU AT _ NAME OF FUNERAL DREG TOR OR REGgeST TDRY. . _1111, o 11 __._. ._ EREO RESIDENT DELIVERING REMAINS. ARzsN . NAME _ _ .. 46ee1we TYPE OF CONTAINER: _ CASE AT �QYr--- aa.PLACE OF DEATH: p(� /I 64µ. , TT ESTIMATED WEIGHT OF REMAINS 8 CONTAINERS PLACED IN HOLD; _ PLACED IN REFRIGERATION - - -- - bo�DATE OF CREMATION --- 1luLm._ TIME STARTED: -- 716 Q �Ott� PLACEDD ININ RETORT ORT _i mE COMPLETED; MOVED p RETORT II IN WHICH REMAINSINSWER WERE CREMATED: 8,M DETAILED pFA50N FOR DELAY OF REMAINS WERE CREMATED MORE TjH FROM TIME OF ACCEPTED DELIVERY; AN 48 HOURS NOTE THE CREMATIONO .__ RM //////������IIIII "enbleSuu EWYORK Division of DIVISION OF p EOi m q Art DP ^ Cemeteries 99 Authorization for Cremation and Disposition role AUMorimanm Form must W completed and tlgra d paper b aelleery d remains Arcm Mion. Oats'. ` < G. O /^ Normala IIW� Craxlay, n yI C ` i0r, l rtrp Aldroom�7 a. kele Phone: S/x ' 7NY - 4y� � CREMATION IB AN IRREVERSIBLE AND FINK PROLES". Comte In nr ate by placing Me mmew of tee d so and Me contiimr rural may remeMe Into a creme nchamber wel MAY are subjected A All beat and dome. The hem and tame lll trinomial antl consume ewMbing Accept bone and me4L which am all Mat ail ll bA IM after crametlon. Fallowing uwmticn,the cremabry will Site mawnabb eflerb to nmoae all of Me remains and u0m material from Me oemadon chambap but same minimal dust and residue will likely be 10 Whied. Ths cremabry MII xperme inDmnOI and resign mabris ton Me remains,and Me Inceentel and human material w1l be disposed gas repubM bylaw The cramamd mmainsvAl be meCMnblly pulvedxd into small palms and Still a dasgnadd mntalnxa um. Cmmabd remains generally are pulwrio d until Ad single mgmx NmwenW le ai ekmwl til OPEN NO OF THE CONTAINER TM cremabry may only open the ormadner holding the animated human remains in limitsed cirwmsPn s, autll ezto confirm Me barley At the deceased or to ensure that no mabrtal is m Joaed Whim might injure empeol or damage Me cremabry property. It human remains are contained In a contalmr which Is not suitable 1w deal Such as ceremonial or rental cal the coalory will require Mat the remains AS, moved Into a su11able container before It accepts Me remalm. The opening da nmtainer or the Awl or removal As romalm Wru be wndu Added a women and wall be done in insect,wM dlenlNand mzpaa. 1 E TIFICATION OF DECEASED a rein . T- �M peas 9r M.db15l,W> m . a.c / S —, it a (rx7ntJ Cfr I . i r enctourL� , yW Place ofDetch A.GIGnS aNs' I ND5(ffbl Sax: El OF Age: NB: L TQl Dawooe : l l7 Zs, EetlmmedweigM�125 � Onaplcn of caeketkmntneri myth mmama wig ba egNema. rvl0.-E�xle p (l s nC re f-na< - � 1p_: , woo .� hor'ram - �� PERSON IN CONTROL OF O ON (Pascal In tanfmld S'aFoaidmtior.MN inN�' IONFgIM/dbw4pl Small are Ma desgmtad agent of Me A,,ym d desgnated In a will or smash Inattel executed pursuant m Public Heath law section 4201. OR- Xai(- sun' i haw no Machete me the deceased Awarded a which instrument pursues b Public Haagh Law Section 0201 or a rp dgMgna far tM disposal of his or her remains and IM are the pedon(z)badnB Moray,under PuW,b Health law Section4201 and have Me toAuthorize cremation of Me remains of deal MyMm relationship 10 Me deceased le as follows'. - ('Igryr,rr DOSI8g0r(Rww. 0aki Page l As Authorization for Cremation and Disposition (learnM1 me am W) / Number Cesmalnn: II) I Y f 1. Apeman designal among pmeuem to Public Neabb use Setlkn@01h); 3. The our inrg aaausei ga. The sumving dmmeAc partner n My wooden rnim elgm w"a+of age or older: s. A surviving parent a. A survivl no smind eighteen years of ape Or older) o. AlawNlly appointed guardianl ]. My perva le)rgster,yeah Of"a or older mall to share In Me meat&and who stare dossst In relationship b the demeesed 8. A duty appointed Money of Me estate'. S. A come Mend or relative has executed a woman statement Pursuant to Pi N aaM Law Sai42Ol(i), 10. A chief frccal oMwr of a coumy Or a public somewhere appolndd ambient to the Surmgak'a Court Procedure Act. lase Any other person wow is aping on behalf of the der&seed and who has executed a wren movement person to Public Mean Law Shearson,am1. rival ALL Tudei of ma mnouri 02:0--IMIa member affirm that the bWyof Me deaaamd does not con en a remains,battery rent Power call radiwcdve imgam. or redloetlive device and Met any such Momals were removed presto Me exewfon Of this AWrM UOn Form. Fallummremnva Mesa Items prif cmmatlon may mum In harm to the c emamry and ^cmmamry gmon". � CIDII anrm that lnawnYonb have been III to )/oYl � en S. rx.( i IVJ RgeNing me removal of any pamrs��l GGwaM a over tlfno M vew/e which m r s Mmon sgmng below or any family member Of Me decntedwlbnmmpreemen U�' nt ✓ieW I rPmA�TTJri WI'Yb ename a noommonai re Mason removal mpemnautems from Me mnsom manom Me remains I deceased. Pamonal ftma lan m Ms tether or with Me remains will ba din° tithe t�in�'a0enpoi and carte be retrieved enar rnmanon. another ague hereby ambodaai i' !12 I/' PW ( a tern.{-D r^ us Y to Membranes the remains W the depaud. L OP90NAL) May hereby auMorlae the named ma l of recmr to provide for delivery M and cmmatlon by an ahamale crannermarry. if deemed necessary In the opinion Of Me funeral dfirmi and to amen this born to provide the correct name and address of such alternate cremamry. FINAL 015PO9110N The pairun aNlw m meet"the movement remains M Me dmasa]mom Me boundary Nam er S!-a ZMait vr� t PMn.: SrK y ­ 4z43T arNnaefdecessd WwlllbadlgwamMmewa: T157fVf n N i--c..m L-1 If for p�YyJ� � th V��/�, nem1d arm`dam lrotbkla�µa i Of Ns aemaW mnelns, a{'A /lc VIC(ALI/ l , j,�I✓l(A TLJ r I l21 'm Is m MWca]to alre possession of Ma remairrem � lAl lso ` (� ff Yleiy i 'ar00.o by delvery m pension of by mgibtmd mat.., '-1 am..,a. ( 16k see [in!t N/ L)U ly"f04 ✓ IX15.1 Mall(Rev.arzo) Paw 2 a] Authorization for Cremation and Disposition ff69@I IIi•ldbwMm © ciD IM/.am•na u.lnme rery�' .re a.claimed vAMm uo aaysdNemamn, V i n E V I PIA l 4f P r7�W r 1 u m narelsao•.otme rema�.ln animukveda manner, such a,by yeteda. CREMATION CONTAINER URN ymIONEd M,lolnwangJ M um b b,use]as• container for the command remains Me Wn amn®.d Fcm and,haw das fr4mm Me understand Nan II N,um Is Wmanm road an•hake cnmaba remains an a]aaanal ngW container may be used he"I -0R- (TJ C I An um Is not yes purchawd. II waerstana that If rw to is purchased of olMwlse provided VV" Pine"eve Cremmonum vAl [fare the Cremona remmme;in a rgld sempamy forsa er Mr delhor. PMmdmam The AUMmh•Non Farm way promdN by �o nex n S. n� I Krri way"woman at n err 12i0 � ���m��� � � � !dQ YYl c "CIM am I spent by me funeral direnm as vane,,m by serration Me have I&I a ocmplHed copy dlhis AunMsalbn Farm. TM pan ows)Id•ntied bba II Ma pemon(s)IO comma of deposition,who by sign Ing the AUNorhadon Form,a"Ing) Is the samecy a"chimplawneas of the lnbnnmlon contained In this Augmentation Farm and auMorls•p)the fongdnp. veaafnta ergs SO� U . If rwI d It n< u ✓ NT7 WAITN\ESS: I J/1nCPss ) . A'Ir+f', ems' /�N Ciarc rP i rrno Or . maws, ims-I& f(RwAllM) Page 3N9