Galli, Arthur Robert Pine View Cemetery & Crematorium
Quaker Read
11ueen5bury, NY 12804
(518) 745-4477 or (Ste) ]45-44]8
FUNERAL NOME; _
04TE B TIME REMAINS ARRI - - RN TIME _
VED pi CREMPTVRY:
NAME OF FUNERAL OIREC FOR OR REGRISTEReD RES,ENT DELIVERING REMAINS.
NAME
IQLLZ _.CASEn TYPE OF CONTAINER: � I � (
vLACE OF DEATH; olM,_H00 F...
ESTIMATED WEIGXT OF REMAINS B CONTAINER F., IIII
PLACED IN MOLD:
PLACED IN ReFRIGERATION � - - ---' -_DATE OF CREMATION Q 30
TIME STARTED: ._.. _.._.._
---.. n PLACED IN RETORT. __._TIME COMPLETED:
igljq
RETORTryIN WXIL MOVED ACCEPTED
REMAINS WERE CREMATED:EO DELIVERY: , fZ'ayGr zh� 3 I ' I
DETAILED REASON FOR DE LAY IF REMAINS WERE C - foREMATED FROM TIME OF MORE TaAN AD HOURS
NOTECREMATION LOG i
Ue RE xME PC
RRANCRTFIC or AfECREMATERY
DisposalIf
4EW OKK DpION OF CEMETERIES) On EE ,mESN� Cemeteries RI
Tweral MIS)474a22a
Authorization for Cremation and Disposition
TWA AU or4 MForm must EecunpMMa aM.IgnW prior M aeewry of mmaMe far Cmn On.
Data 9-I6-2000 Number. /Vqj
Creamery Name: PMev CmrnMay
Ack recta 21 DuMY ROW, Oueensbury, W t2e04 Phora: (ste) Tawn
CREMATIMIS AN IRREVERSIBLE AND FINAL FROCESS.
Cremelion a cemW out by placing Me remains al"deree4W and flow vradminer al Me anaiM I=aa "On MOM[ x M
Nay ere sugeN]b lnWnae Mel and Pama. The Mat and flame will Incinerate and coral ewryNMO sa ddi bom and mNl,
whlmarcaNNxwln W NhaMrOmmadon.
Fonowlrg uamaoon, the crematory Fall take remonabm affords to remove of W the remains and aher ma0mi o-dn the nemadon
chamber, that some minimal dust ads r due art likely be left aniM. The uemaLOry All sswrale lMd Ni ads foreign manknd M1wn
Me remains and meactional and foreign maknal Fan the dbposW maa Sall by law. TMuem rc alns FAlL mOMml"N
pulrerhedinto small plows and plated into a AwxMaled ornomur um. CNMWdmmWnagenemllyampulwr uwlna
ampsmgmenuemcogntr bW"$MJ 69$sua.
OPEXW OF THE CONTAINER
no aemetory may wary Iran the uncommon hoo g me uncremaded human mmeins in limited counsel such As as cwMm the,
heathy remains
em ds am delivered
e container
rsam se not Suiableh might inlureemployea ordemepe or CremMdyggMy. M
human mn.Meamd;Met dine alms So Small
Int not Suitable rorcrnm.uoneumas the
or soul aopolo
� awrvrth meum Wruanmammma"Mh wMua bMmaminn Andrefory the don Me amass. meopemrg Me
rNrewlner ormalranarer or removalmremmna NailMmndaaaa Mfineawdmm amwulMaom in pmaw.with dgmNeW tmpxt.
IDENTIFICATION OF DECEASED
Name of Deceased AMWROMM1Gain MonYISM1uz manned
M tttust Groove lewd.Olcen Ch, NY tomes
Last Nnwm Mdr
Pam of Owls. SI. PSmM1 Hm l
tea , Elm OF Am. 93 Doe: 02/14/1927 Dam of Mh:Mlfi o EmWmdwapd I 7O
Da on of m'retlwN win any our remains vau W daliwred. // �� �
Cardboard Box wM/ooden Base (lam A 4n5 fL �C1�10
(Po n(s)in Imlw w mspomawmn ' oONE mine wroainp)
I amMO am Me dsigrumd apeM of the MmmW dWOnemd In avail or watchIns"ment mi purwtanl to Note
Xeehh Law Season Q01.
-ORr- y
i Law have no itnowledge that me dames] exemled awrltten instrument radial m Public Heads Lax Seclon 4201 or
van containing direction for Me dispmltlon W be or Mr rename and Ids are the commands)haNtg pnordy under Public Sel Lax
Section 4201 and haw Me right to aNhorua coal of Pe remains ofdadecemad Wyurm%tlmbiPW e»deceased Is as
follow
Arthur Robed Gal
DOFle0Bf Mi Gui Pa p t ois
Authorization for Cremation and Disposition
anwdrm tar Persona
Number� Gaaoip0.^n: Coral Galll(Spoum)
1. AFerman dealgnOedin mining purWanl b Public Health Lew Sa(rs 0201(3):
2. The survMrg shomme
re. no wrvMrp dornestic partner;
a Any mnlmry cola elanmen years or are or oil
a. Awrviing paprR
S. Awrvrvint sibling agMeen"am of age or odder'.
S. Aawwrlly ppoi nod gundan;
1. Arty person(s)elOMann yeah of aft,or door enbUW b share In the estate am"a Were caavlln relatlmuNp m me dwraeed:
S. A duly appointed Marcos of Me"ham.
S. A does lrcM or relative who ha payWod ewnown ammmeM Funuanl to Pu lcH Mlax Sol a3019);
10. A Proof Moil olfimr of a county or a While dministrator madmimo pursuant to Ma Surrogate 5 Could Pramoma ALL
10a. Arty MMr"Mon violsactinfonbehalf M the dereel and who has eaeWod a where statement herauem to Public Heats
Law Seirmn 421.
ftufidI ALL THREE of#o WmArrre)
IMb hereby affirm met the body of me daremed Mail nth¢Moan a omen, money pace poem mn rmio r lve implant
ormdmaavrdev aMOWarrysu mamdalswemmn prmrto eeve[ onofmis Aumw/estlm Fomm. Fallureteremove
mew Name pdvm cromenm an"Main in ham try me memarm ma cnmamry wrforil
NAB affirm Met Mmlruclwn haw been glum to Rolmno G. Hi
regarding Ne removal of any peramal gopeM or not thal of value whop any persm Agnlhg no me any family matter N the
denial homes to preamve. Pbn Vlaw Cmmamry
e nor imperil for the removal of Pononal Items from raw mnmlner or Man raw remains of Me destroyed Penowl Items loft In raw
/newmet M whim the home Ins will M destroyed by One,Mail pm teas and cannM be mail after Miami
} b Me hereby aumodw Pine Yew Crematory
hcen+unho W cremi Me Mail of tM dauaed.
(ICI IONAQ
Lore herby aumodv its named funeral dIMCW to provide her deMery by and cremation by an albme4
rp outcry.0 deemed nerswry In Me Win Ion of Me Nrerl director,and m amend Ml$form M provide 1M moral name and
address of such alternate crnwbry.
FINAL DISPOSITION
the parsm amnodree to remove the command!hmulm of The dewam Nmn the ermrmry is
Name: CcenOSSMao Full Cam
Andress: Q2 MarYe Am. Swaney¢ Sgngs, W 1205fi ppoe. (515)59LaiMa
The oamrme remains of mwmm wiu be disposed of as folowa:
T
N W my MeaMl ne Finam named Wma dcm ant Wine pomation dme 4alWed mil
Plan Vera Coal u authorial w gi rommeandl of
rtrrmgwv)
they mnmum CMnpooreb Furval Cam. IM by delivery
in"mn a by mgmm ol mall. ever,sMom Arthur Robert Gmi
S-IG�f(Rev. OM201 Isum DO P&M 2 of
Authorization for Cremation and Disposition
CMJVdr MB wmwxly)
IAthe unaersrana Met If we nmeins era not cable!WNm I days a ertma8on
Plan VCw Crematory
an Methanol mannm, such as by dupenrp, r �rv�� mM deP°bINlde remain In
(TnIMONEaMe M1llbotnp)
�An um to M Uq1 we ¢washer W Me vemeled ramairm lue been WMase!wam
erN ie daacri�d a81dIOM:
IAl uwer wthat X Me Um i besawl to hod the enpre rMwakd remains.an aMiwealtMet thOtsaa may M ueed br delivery.
//OR�y.
` A MUm i¢mtye(PueUN¢et lMb uMershMtlW pno um i¢Wrcheeedwppprxipapovked
Pare view Grememry
m+weOm.ass MI Pram the riematM rauuinaln
e n9id temporary Wnmim M defrvMy.
Thb SUMwleatlon FOrm wm youNed py Raised G. XOp
� was amounted at
Compa¢¢mpFurcrel Cye Irc
m W
402 Maple Ava., Seampe R- I, W12M
and Is wall py and Nrerel(MI as wtmn mite erewtion�wrr
IMb have awned 8 wmgen d COW a MIS Autlgrizaden Form.
1 MM oneldentllbd hate,lehm Me Mmorde)In Coal of dlspltl wM wum W slpnl UNrq pis A atbn Forms washwa(
accuracy and Wei Plaaaes aths IMermal home lead In MIS AUMOhfwSWn Fears and aurM1Odw(s)M&bnpelry.
sawed MM tthn dayof September 20 20 q
CallGalt c&S L 00
2n Locud Gmm Road.GiaaaaM on W Ion V ��U
WRNEBS: emvru'ro .waf—=�
liall6la�G. XOp
m 11636
Arthur RopM Golf
wmas�y
DM18l nMv Oadal Pawl