Luciano111, Louis J. PI^e View Cemetery . Crematorium
Quaker Road
Queensbury, Ny 12804
(518) 745-4477 or (510) 745-4476
FUNERAL NOMe: MAW-
f�A1C - RETURN TIME
D47
E B TIME REMAINS ARRIVED AT CREMATORY;
NAME OF FUNERAL DIRECTOR OR
4RISTEREO RESIDENT DELIVERING REMAINS:
NAME -YYkIE,V[r ---.
[ _.
U
zr
TYPE OF CONTAINER —cRSEM low -,_ _-
PLACE OF D � 4db®EgTM: _ J1(�O� I Lf4AEiY(N
EETIMATRI WE1ONT OF REMAINS X CONTAINERPLACRO IN HOLD
_ 1`
PLACED IN REFRIGERATION: _ --
DATE OF CREMATION: __-
__
TIME STARTED:
o"AT) —TIME COMPLETED;
PLACED IN RETORT A-ppy -'--
�V RBI _. . MOVED I
RETORTII IN WHICH REMAINS WERE CREMATED: Cw _fo wwl�
DETAILED REASON FOR DELAY IF REMAINS "HILL CREMATEOr#m -OK
FROM TIME OF ACCEPTED DELIVERY: MORE THAN pS HOURS
NOTE - 9TION LOGSN4LL Oe n¢TgiNEO Ix )'nE nEpMANENTFILGOFTNECRIMnrORY.
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�TAI FORK Division of mv'MorooFCcill"PiEs
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Authorization for Cremation and Disposition
This AUMangficn Farm must as Completed and algm Nonhereditary OI��mNNsain$IWcmnalbn.
Dare.SeaMLY 22,2020 Nuntm: F�
Gmmlory Name: Pins Ye o Cre rni
A mss'. 21 Ounder ROW Guee SWb Near York 12809 pMm_ 5d7adda77
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Creomtion Is wrietl out Ey placing the remains of the de omsed and me Container holding the emans infra separation Chambn akwre
they are gmaseWt0 irdense Mel and flanre. flow flight aW flame alit inclnmvm and consume ev Ming except bone and owed
which am all Mat will be IM after cremation.
Followingcremation, the pemetory vnlltake reewneNe dr to rnrrne all of the remains and other malenal from Me comet
chamber bid some minimal dug and residue wall likely M Its behind. The unnabry well "prate integral anal foreign material"in
MeremainsandtW,WdemalwdtmgnmalenalwillMdispx as yuimdE law. Thecrematedremainsverllbemetlien'scary
unsweetened small pieces and pla2dlnto a designated importer or um. CX abtl Slmpmmilyampulvedsdur ino
single fmgmentb racognlvbleaa OW lburns.
OPENING OF THE CONTAINER
The crematory how only open to container holding Me unCTmated human parroain limited tiramstarices, wed as In confirm the
KKn4ry of fire de red or to ensure Met no material isentlosetl which might Injure empbyees or damage the mussel property If
human remains an delivered In a container which is not suitable for promotion such as ceremonial or rental GSke Me
meWry will repulrehen Me remalm be meved InW a aolbbla contaimr beam hancepb the mmalne The openirg Of a
container or the bander or removal of remains will be conducted before a witness and are be done In pMaca with dignity and N apM.
DECEASEDOFITTIFICATION OF
Name of Depea Louis J. Woan0111 Maritl Satin: Never MamW
tall Known Address 6 LenauoW Temw South Glom Fella, New YOdr 12e0J
Place Of Doubt Glens Falls Natural INS Park SI. Gans Falls, New Yak 12MI
Sex. ® M OF Age:52 DOe. 09-26-1967 Data mown W-21-2020 Estire reb Might 150
Dependent of raskeV ta'imr in which remaim will be delivered.
Florence Casket, plywood corrugated cardboard container.
OF DISPOSITION
(Pan OVIa a,nbaor abnormal LL ONE or Mp mdeaski
I uptake we the designated agent drum tlecnas]designead in awill or wn0en instrument exerted pursuant t Public
Heim taw secuan a201.
-OR-
%S IMl•lave n0kmwatlge find Me Seemed executed a wrAan nonparipursuant to Public Heauh law Stepihn@Ot at
WI mmeintlq tlbxuons br the approach of his or her remains and law are the proton) making pnonry under Public Heart Lew
Shun 4201 and havethe note to aumonse monsoon ofineremains Of the tlxcesed. MylOur MIOUD Mp W to deceased is as
follows.
Louis J. Luciano III
DOS-189i(Rw.M(10) Page 1 0>
Authorization for Cremation and Disposition
(uaaert from me Ilu nalaw)
Number:3 DeanigAn'. Any surviving crud eighteen seen Of age an All
1. A person designated in w'rNng punuam to Pubic Health yew realm 42( pr :
2. The Formal space,
a. The surviving damesdc partner:
3. Any school child eighteen "am of age or older,
L A survwing parentl
5. A surviving sibling egnleen years M age Or down
5. A lawldly appointed guardian,
T. Any peal l ArseM yeah of age or older entitled to share in the whale and who crew company in rparrou ip tithe Jeuaudi
8. A duly computed Oduciary of Me 6tall
S. Acloae blend or relepve who has Accued a women statement pursuant W Public Heats Lax Sedon 020M.
10, AUIBf fiscal officer of a county an a pudic announcement ameded pursuant W Me Suacgem's Coup Procedure Ad;
real. Any other person who is acting On behalf W the deGased and who has exeomed a when statement pursuant lO Public Health
Isw beach 4201p1.
GALL THREE aihe malwangf
lI hereby am=Ihe1 Me may Of the dettased does net ordain a battery, ban" pack, power cell, lateral Implant
an Wm ve tleNce arm that any won formula were removed prim b MeavenNot of this AUMarlai Farm. Failure bmnove
Mw items prior to counsel may molt In harm W Me annual and amend" temporal.
t Arm that MsouNons base over given to Clain C. Koncel
regar irg the removal of any personal propeM or other Ming a value whipt any person aboard below a any M irycheaper dM
decreaed women W presre. Pine Yew Cremelay
is mat reaponaiae for the removal of Moral hems from the antiand or from Me rlemains W the depaaa. Panonal IWms Ian in Me
Q retainer or MM Me remains win M de" by,Me cre auon pours and cell M mVleved after cremabon.
]cj'f ll hereby awhanae Pipe View Comment
rc
W aremm M.will neaMe eea..ae.
( INaI OPTIONAL)
love hereby autua In the named funenl dlrectorto puvide Wrdellvery W and crom on by an alMMtO
conermatfory,If deemed necessary In Me opinion of Me Funeral director,and t0 amend d is farm W ouvWa Me co so name and
address asuch substrate crematory,
FINAL d3Po5nION
The pension defended to receive the armaled remains W Me deMaSM hmi the vdnamy iw
Name M. B. Kilmer Funeral Home
Address. 1 W Meru by SOM Papers Falls, Now York 12803 phone 518-74"418
me cremated remains of dxwaed will W dupoud W as fWoaa
Burial Mine vale,um
It for any meson the person named rtwe does not bke poame tithe ammM1d nmams,
Pine after Temaory is audwAdd W gore Powerful 0
cs..mlxrn
the rertalnsto M. B. Kilmer Funeral Home by chiral
pyrw,
in Wr or b/m0ysmdJ mall. Louis J. upland III
COS-18W-1(Ray.04QO) Ppe2of3
Authorization for Cremation and Disposition
�babilttheAssawal
LL1Jl INJB underareno Met it the remains are not nimeE within 120 days of canner,
Rn¢Uiew Crematory mry disyee ofMe remains in
an arrsmevaMe manner,seen as By amnaring. w¢ mr
CREMATION CONTMNENNNN
(Irvda-1ONE of
Ron
Antennae)u
n r��A,n um tooas aeda>econraner for the aemeted remMna has been pwWUM hom M. B. 1(Ilmer FumzlWma
and Is desoibed is knows'.GRni1CMM Near Um Blue
M understand that If Me an ISM small W had Me entire cremeled remaW,W M]Mnal n0M mntalrrer rnxy AS used for delivery.
OR-
An um ve net yM purtlund. IMN understand]that Of no um la WrMasad orM ioname provided
Pare VIM Crematory, rnll maw Me uemetM rema'm in
p+nncm+w
a Wd tamporan moral Or comeary
This AUMo SOS Form was provided ny Claire C. Kmp.Ma ra>tio,.vwsl waa esecWed at
M. B. Kilmer Funeal Honre
IN Main 5L SAM Glans Ftlls, New York 12WN r....✓xe..m�.
and is signssEy the formal MrMor as"non to its eaemikn u
INVe have wwrve t a completed why AMIS AUMMMWO Form
The W Me arccuracy and comPfied ehow t lasses of Me lMormadmn ccoonUrwdi MIS AMhaMmdonl Of hasivassilicin,who by eFnrm and au QMd s)Me fGTGOW.11s)
Bymd MIS 22 day W Bememner 30 20
1e IC �1(10 . I r A nViIL
sn,.,.... am+w
WITHM:
Claire C. Krwopka eP.. emsr
m
11932
Doubt J. Li III
OOS1 ONI(Rev. 00120) Papa 3of3
Pine Viea Cemetery and crematorium
21 Quaker Road
Queensbmy, NY 12804
Authorization to Separate Cremated Remains
Funeml Hone ___--- - A6____S_w'_�_------------
DiFeNn ----C4Lt'-----r ------------------------------
Dme
510)10 _____ra luo.__Ey6__------
Uwe RuIlto ve (lie separation of We ncnMed Icluwm of
(ours [LrLpuo 7$•
Uwe fmilurµ eto bald Ladles., indconify and defend the heroin nvned eremalolium wt well
Ae dmlr rcpmsemalives, fro And µal¢t :dt Claims, Ihkl) hies or dr anµ s whmsocecf which may
nr
result I'oan Ihis amhoriml�u I
Sibnutnre _ _�____—_ _________________
Gemuury o1 eimor - ______- ___—(�'__—__