Manzueta, Melba R. Pine View Cemetery & Crematorium
Quaker Road
Q Meensbury, NY 12E04
(518) 745-4477 or (51a) 745.447a
FUNERAL ROME:
_.__.___
._FbPfprb7DHn
(LATE a TIM -"-'---- RETURN TIME:E REMAINS ARRIVED AT CRf MgTORy; -NAME DF rONERAL DIRECTOR OR REGRur
__ la
FRfD DELIVERING MAINS
1. RESIDENT D
. ^� FRIN6 REMINS:
NAME.
- -
_.n�L (a ---
TYPE OF CONTAINER 4n'L. I rL - CASED
_
PLACE OF DEATH: ySI My( Ux/ 4W /
ESTIMATED WEIGHT OF REMAINS g CONTAINER
11
PLACED IN HOLD-
—PLACED IN REFRIGERPTION: ---��_
04TE OF CREMATION
TIME STARTED, Nita�I� --._..
PLACED IN FRED RT ��,�p].�JW_-TIME CO E (� �
-. MOVED
RETORT pIN WMO:N REMAINS WERE CREMATED: **
G ,
DETAILED REASON R O
NEMgIVS WE
FD DELIVERY: NT OREMgT
FO FLAY IF FROM TIME OF ACCEPT ED MORE THAN qp NOURS
NOTE THE CREMATION LOG SHALI, of REI
AlNro IN THE nERmnNExi FllE OF THE Cx[mni0 y
WEWYORK �IVISIOfI Of N.Permrrnersr.n
STATE OF DM510N OF CEMETERIM
0ov: Mny Cemeteries One C"Weri Ple,
Te Mmibill
Arter,plA47 lfe
Authorization for Cremation antl Disposition
MIS AumM a Form must be completed and Blend War b delivery 0 r alm for Cremation.
Data 9,22.2020 Numbs. logs
CRmabry Name. Pine May Crematory
Adrex: 21 Daniel Roe], puemrtW NY Sell p� (518) 746-4477
CBEIMTION IS AN IRREVERSIBLE AMD FINAL PROCESS.
OmmeWn la wined out by placing me remalrs M the de as and me painful raising the remains Into a pNnNan CumberwMre
they are appal 0 inYme bear and items. Me but and Beme all lnci MY and consume owns ing scup[Cone and metal,
which ale all Met will be NM1 Alter cremation,
Following came man the oema YFell lake re $Onable efforts to remmg aA o1 the remains and other material from mat creme
deeper Me some minimal dumaM ha Jue will fil Ca attached The vematay all separate I nWannl and areign mmriel Sam
Me remains and theinoue ll and Sol Fruit AN Wdiepmed deal required by law. The entrance annual will AS meNwn iy
pulerrilem mic anml pNYe and Name imd a deugmkd mMsimr or um. Cxmatee mmame eenemny em pulxdaed unul no
single fragment he recognizablex sk lBxue.
OPENING OF THE CONTAINER
TO crearal may only OPoe me currency hating Me uncremal human remains In Iim1Yd Grcumelanres, such as b api me
idenmy of Ore de setl Orb ensure that no malencaene0st]whichmigMirjunemployxs or damage me cra Me pu qff
human remains are delwrM Ina cmuser which Is not suitable for dmmmmor such as xremi or xnm xskel,lm
crematory willrequlx Loral remmm be moved me a suitable caMaMer b m N exxY the remtlm. The assay;Me
wntaineror NlbansWwmmOv otremair wllxwMuc Ce awlmmsand WWIIWdare InpnvaoywithdgnilyaWrmpect
Wl1NTI5CAIUeczn
Name of 08Ceax MNba R. Math Mor An W
Let Known MdM 131 Lawmnq Strut Sa"a Springer, NY ONES
Place of M: ital Health care Dayton
Se.: OM El A;rs: BO war 11/23/1939 ggYMDeaM. OINSWO2O E.dmem VYpM. oD
Oxcr OOn Of cummmainer in which remains and be mN"re . /
C db rilB NJood B L�vdbi c�p�
PEEd4
lPenn'rlalMeonrrd Wdisposenn. a�rl orvEdme mAatwngl
I amphe aye Ore Wsignaled agent Of the eexesed desKnl in a will or wMmn inammem ayrecuncd purmantto Publk
NeeM law Setlkvr 4201.
Jr/— IM4 have no kno edge that Me demesed exmncd a women instrument purwant b Public Meenh Lew Damon 4201 Ora
i nowli dirediom No Me disposition milk or Mr remains and IHrc are the p n(S)hanrp priority under Public Hal law
Saxon 4201 and mw to ral m euthoi cremation of Me remains ofthe mwum]. MylOur nlNomM1tp b me dacxsed Y ee
bllwn
Melba R. Manzuefa
DOS-0Hart A Orm, Dow Page of
Authorization for Cremation and Disposition
(Mail Man Me Natural
NumM'. 3 Ge¢cnpfon 'MIYm MsuuNe (ST)
1. Algr¢on de¢gnNOM In acting pursuant In Public mail Lax Smon4201C).
3. The warring Name;
]a. me¢urviwrg ecmesbc banner.
3. Any Surviving Chill effmin bean of age or ddx;
l A¢urvlwrg parent.
S. A¢urvlrtng vitro cereal Years 0i One or Older'.
0. Alawelst appeal puaccarr,
e. auPapPoln)cartelder oarymau«�;bell mail to Here in m sate and whoal closed in mlabonehb b Medameyd;
9. Atlo%Mend or real who has GAUMmd a annual sediment pur¢uenl b PUNIC bmM Law Simon Q01(7):
10. A(CON Nice l Officer Of acourby era park administrator appointed pursuant to iM Sumgeh'S Ccun Pm um Nor
10a. Any other pmawi wb IS earth an behalf 0f ft de2al and who has mcbmal a when ste ON mrsuam to Public NNM
law SCOMM 4$o1QA
FORCE be Me loemi
IMb hereby CAM Oat the Mary of Me dememd Uses Me wnbin a batten, I atdry Pontt pCwar Met radhmcEw MpIMt
Or Mmactive moved and Mat any such marble wine remored Per m Me,emsxon of has Aumwiaatlon form. Fawn to remove
Me seder to Cnmalm my mun In ham to m C summry am cramaWq Personnel.
IM6 affirm ma11m0ucMm¢navel Wn Oimn b Rolland G. Xing
Boarding the remove)0f any pommel pOlgny or other"M Of wi ue which any mein sipnlrq Cohen or any kmlly mentor N me
deceased melee to pramrv0. Ron u'ew CR ma
is rim respcmlMb for Me remorel or perwnal lbm¢M1dn Ye wnlemer or npn ft remain¢of Me dememd Personal Items bah In Me
Con •or wlin Me remain hell be destroyed by Me cR Won pm a and inn Me not retrieved after c remation.
Me hereby aumoRm Ron VbN CPome
®..sew
NO mmN Me male of me de ed.
(haNYOPTIONAL)
IMe hereby euMi Me named N ram I MM1MrNo provide ter delivery b and crentral by an albm ed
arematery,it Mamad nemaary fdirectoram c in Me opinion of Me director and b end Mle form b provide the comet name arm
ddress of such alternate cremewt.
FINAL OISPOSITION
The pmeon aulhomel b ma lwtmme means done M¢ hen f mmabry I¢:
blame: Cmpaaiomb Funeral Cam
Aram. do$ Mapb Ava., SaraNciatimaga.NvtI089 p a. (518)5St<MC
Than Connate]MMOIM W dewa¢M MII be druscmU Um Mean'.
Furl TO Family
I b My mein Me mmm naMd scome Uses net MMe pmnsoon&Me oemabd remains,
Pan vary,Crmemry 1
m ¢eNhmmE bgius pmseation of
Me remansto CmPauionae FUrwra Cere, lm Mdelbary
in prawn or by m]wmail. Idl R.Mama
ro+e
005-1S -f(Rev. Ml$O) Pi 2d3
Anuuttthhooriution for Cremation and Disposition
n Wn>noanp1
Nib understand then l/tle remains are mlueimed v.Mln 130 data o/aemation.
Pim Mew Cremmory
iw'»v�mn mry d'repo»dtlp remains an
an nreMaveela manner.sum as by SOMdng.
(ACNE W Me rdbwripl
M um by N as a cemeirerfor May canebd rameim may,been WrM "in
and a daapial as MMs:
IMb undarmand Met i/Me am ire small he hid Ma eM2 aemaW mmalm an Stele l rgld container may be neon br real
W—on um Ia not"t pmN NM uMeRbM Mel it no um'orry Aa98d Or oN wpowers
PneY Crystal
Mem will place the cremal harem ,
a rim bmryRryw wiw M eshery.
THIS AU atlon Form wm pm'^dad by Roll G.HOW was erxuied at
CompeaabnPe Funt fug, line
JOf Maple Ave., Serelo0a $pmpq NY INN
lieri
and ie SW Or to All director as vAM¢N W ib Semmes
i home hall a wmplabd Cl Of thus AuMor on Form
The mm al IdentMled Mbw Were the,persomml in mrat W dim poi who Yy signing MS AUNotlallon Form,attel
b Me 21 racy and compbbmm M this InlwmaMn coMa tried In Nls AWMrl "M Form and a borieeml did brmomm.
Signed this 23nd day o/ SmbmEx 2020
Will Mannino
39 Van Dam Sri p/y 1 E Samaime 5pmga NY 130% �n
ryrwo- wm �
W Regard R
Roland c. Xam I//•`
m 116M rmvenmwxe� p,Myayy yFl
MCIW q. MsnaMn
lwwwsa
o03-0Sg8J1Rev. 0Y30 prtill