Cartier, Ruth M. Pine View Cemetery S. Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERALHOME:
-_.__.__.BAD
DATE 8 TIME REMglry6ARRIVED
- - RETURN TIME:
g RRI V EO AT CREMATORY:
NAME OF FUNERAL DIRECTOR OR RE4pIgTEq Eo RESIDENT UE�I VI�Efl IN6 REMAINS:
kELbYY B.Lp)Np_._-_._
NAME:
TYPE OF CONTAINER -CASEX )Do
�R
PLACE OF DEATH; !! I
_ �'T I•��c t4f y}c
ESTIMATED WEIGHT OF REMAINS @CONTq NER II
PLACEDINNOLO: 13c Lf /II>IJ(
PLACED IN REFRIGERATION: -
3+lre_pd_—
DATE Of CREMATION,
II
TIME STARTED: _ �p 4m„ - 91TZ(TO
' I TOM )y y`
PLACED IN RETORT E CO
rs
/D Sd All . _MOVED
RETORT If IN WHICH REMAINS WERE CREMATED:
DETAILED REASON FOR DELAY IF REMAINS WEIE CR6 CREMATED A
FROM TIME OF ACCEPTED OCLIVERY MORE THAN pO HOURS
NOTE. THE CREMATH,
R LOG $ -- - --
"Authorization for Cremation and Disposition miscom c e.ras....
Puble,NYinsi
Issas neaxzc
This Autumnal Form must be completetl and signed prior to delivery of remains for cressaFlpn.
Ddfe. g III)go Number ib9D
Crematory Name: P'ne Yaw Cematory
Address: Quaker Road, Oueansbury, New York 12804 Phprie: 5181145-0A77
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation is carried out by placing the remains of the deceased and the container holding the remains into a
ematlon chamberwherethey are subjected to intense heat and flame.The heat and flame will t W nerate and consume
Mhing except bane and meNl,which are all that Paul be IM after OemMan.
Following cremation, the cremarory will take reasonable efforts to remove an of the remains antl other material from the
cremation chamber, but some minimal dust and residue will likely be left behind The crematory will separate incidental and
Foreign material from the remains and the incidental and foreign material will be disposed of as required by law.The
cremated remains will be mechanically puloerized 'into small pieces and placed into a designated container or am.Cr mm
remains generally are pulverized until no single fragment Is recognizable as Are eGl done.
OPENING OF CONTAINER
The crematory may only open the container holding the umcremated human remains in limited circumstances,such as to
confirm the Penney of the deceased or to ensure that no material is enclosed which might Injure employees or damage
amatoryproperty. If human remalnsare dNhrered In a coitalnerwhlah Is not suit eMrrcremadon such as a cewmPpwl or
rental purket,Me concert will require that the remains be moved Irrto a suitable wntalner beore k accepts the remens.The
opening of a container or the transfer or removal of remains will be conducted before a witness and will be done In privari
w¢M1 dignity and respect.
IDENTIFICATION f DA a OF DECEASED � Al.
(n 1 e r Marital Stetus: Mare Name of sates �t,�) 1—fl
"at known Address: � { Cnr+ierin FA Ai d!l 1 )k2-I
Place of Ooal
Sex. OM 4F age:�C_ OOB: Date ofDm[M1:� 1917of Estimates WeipM: /gs-
Description of casket/cln ainer in which remains will be delivered:
Corrugated Cardboard Box with Plywhadid Starmark Model d 38808
PERSON IN CONTROL OF DISPOSITION
(Person(s) in coRml Of disposition, initial ONE of the following)
I ant We are the designated agent of the deceased designated in a will or written instrument Executed pursuant to Public
Health law section 4201.
OR-
/We have rw knowledge that the deceased executed a written instrument pursuant to Public Health law section 4201 or
a will containing direction for the disposition of his or her remains and(Continued next page)
/l
page)
L Qr ier
WzraiHn al..m/ml xmrcgIXvmN Pal
I am/we arc the Penchi having priority under Public Health law sectron l and have the right to authorize cremation
oththe remains of the deceased. M1ry/ourmNtons ipro the deceased is as rolbws:
Hai the so III
Numbar'. J ceacnpbon.
A person designated in wartmg purni Public Health Lew section 4201 (3).
The surviving spouse;
U. The surviving comedic Partner,
0 Any surviving child eighteen years of age or oatsr,
4. A survhing Parent
5. A surviving sibling eighteen years of age or older',
5. A iaMuily appointed guardian'.
T. Any pergarms)eighteen years of age or older entitled to share in Me estate and who islare closest in
relationship to the deceased;
a. A duly appointed fiduciary of the estate;
9. A coast friend or relative who has execued a written statement pursuantto Public Health law§4201(]);
10. A chief fiscal ofgcar of a county or a public administrator appointed pursuant to Me Sumogateir Court
Procedure Ad,
10a.Any other peROn who i9 dating on behalf Of Me deceased and who has executed a woman statement pursuant
Up Public Health Law§l.
rat(jplfLLTnaFF aj lhejWowmpJ
CIMe hereby affirm that the body of the deceased does not contain a battery,battery Pack prover cell, radvaRie
,in Ian[.or radiwttive device and that any such materials were removed prior to the execution of this Authorization Form.
Failure to remove share hems prior to ormazbn may mutt In harm to the nematwy and company posennel.
I/We hereby affirm that lastNttions have been giam to wi ovrv,mmie Cnssv aofleMM313M regarding the
C of any personal property or other thing of value which any person signing below or any family member of the deceased
wishes to preserve. nummM canal Pine View Crem not responsible for removal of Personal
Personal from the container or from the remains of the deceased. Penal hems left is
mnulner air with the,imam will he
destmyad by the cremation proms and cannot be mrieved after aenatbn.
//11 1/we hereby authdme(u ,vrnm=r Pine view m md M ew Creatnry to areae remalma
th 5 rmsed.
FINAL w5PORTION
The person authorized to receive the cremated remains of the deceased from the Crematory Is:
Name: Baker FrinevalH Pensommeal
Morass: ill fhrette Street Clueenstury Nex York 126" Phone'. 0518)761,9303
The cremated Honduras of deceased will be disposed Nos follossa'.
Retum to family to be decNed
If for any reason the person named above tloes had fake WdwWon of lire cremated remains,
reveal Pne Yew GremaMry is authorized M give possesaicn of Me remains to
mmovf�rvvr Baker Funeral Nome by all in Person or byyy registered mail.
normal inn.mbar �.QY sl<r
aw,.wa.,n.d . e :xa
M1e/alhowln9l
•/N/I I:understand Mal IfMe remans are rid chimed wiMln 120 days of cremation,
t �,w) Pine View Cremstary may dispose of Me remains in an iner>;euable manner.
such as by scattering.
CREMATION CONTAINERNRN
In WONEo)MeMsiving)
—An urn b da used as a consumer for the cremated remains has seen pu chasad horn Baker
Funeral Home and is described as follows:
N16 understand that tithe um is has small a hdtl the snore cremahW remains, an additional rigid container may be used
for delivery.
O -
r An um has not yet seen purchased lags understand that d no um 'apurchased or atheneum providetl romiemy
oamrel Plne View Crematory will place the cremated remains in a rpkd temporary
consumer far delivery.
This NuMon:atbo Form was provided] by r mfdrrrz.mwmmel Ozza BarfemxlalW
was executed at chw,xmemmo Baker Funeral Home
chrasrnorre.emr,) 11 Lakvatte Btraret Ouesnsbury New Ycrk 128M and is signed by Me funeral director
as wipless to its exeWfinn.
trrM have received a wmpleted copy of this Authorization Farm.
The parsons) asentified beaw comes Me person(s) in control ofi isposifan, who by signing fhis Authorization
Fmm, afRsf(s) As Me accuracy and wmpleaness ofthe information cmfemetl in Mis AuMoroaQan Form and
eWhonze(s) Me Mreyving
sl�r,eanm.A asyw eC��,�j 6y, �
PI ., Ar (a 1Qo „-ILL N 14-904
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WITNESS:
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