McKernon, Jennifer Lynn Pine View Cemetery $ Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME; _ ___
____ S S.P
- '-- � -_ ._.. RETURN TIME DATE 8 TIME REMAINS ARRIVED AT CREMATORY: aI)I
ID
NAME OF FUNERAL DIREc 1'OR OR RECR4VFan E0 RESIDENT DELIVERING REMAINS
NAME
TYPE OFCONTAINER:
CASED
CONTAINER _ -
PLACE OF DEATH: yy
ESTIMATED WEIGHT OF REMAINS C CONTAINED
PLACED IN HOLD:
PLACED IN RBFRIG RAYON _ - -- - -
L y� Pn
DATE OF CREMATION: -- _ —
TIME STARTED; - -- - - -- ��j0""'- '
110fi .. . , TIME come FETED: n[IZ
PLACED IN RETORT.
MOVED!
RETORT 8IN WHICH REMAINS�WERE REMATEO. - - /�tff dYl 2A
t jry
DETAILED ---- -----fl�(Y__���Y _
AC REF FORDS LAYlEREMAINS WERE 011CMATED MORETHAN40HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE ATION LOS $
Ni Yak Surd,
Oe memNa
NEWYORK pIVI510110f O SWN OF CEML IES siRIFOF UrcC P
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Cemeteries wpm
510)0446226
Authorization for Cremation and Disposition
This Autlroriation Form must W completed and Signals Prior W Masi of remains for Omani
OWN_ 091 Nudmer 1031
cremabay tame:Pine View Crematorium
Address:51 Quaker Road Queensbury NY 12804 Phdnz (518) 745-4471
CREMATION 15 AN IRREVERSIBLE AND FINAL PROCESS.
Chemical is redels out by pawing Me remains dMe decent and the container holding the unrest Into a cremYb^M8rrGer'.Mem
May are wgecM he intense heat and name. Tlw Ireet and MmewllNndneMe end mtume eeerrlMrW uupl bone end mMY,
which are all awl will be Wl ante chamber.
FdbwlM VemNion.Me crematory an tells reasonable FRORe to remove all Of the remains and Other mate„al seem Ind owe64on
chamber.but wren minimal dust ant residue will likely by Ind behind. The vemNory will seperele InckeMtl one brei9^uneteriel hot
the fememaant McInaaemal area roregn merenel wuI Ee aYpoaedaeS honoirels by law'. TIWaema remainswdlbemBSNni
purnermae into small pieces and Faced into a Moderated ounces um. crwtttls wrote een.wlh an pula.rketl until ilia
single Designers is namelessness as akMN l Made.
OPENING OF THE CONTAINER
The customary may only often the container homing the un�mmetW human remains in limited circumstances such as to venom tic
identify dthe dears ed or ensure that no metenal Is cadmium which mghl lryure cmplcyess or damage the mandatory Pedtrty. H
human remains are ascent In a commissar which is lid suitable far cw gon such as ceremonial or ream casket the
matowlll rpulm MetlM remains Merued Into a notable model b m it accepts Me remains. The opening of
mnlamerry or Me transfer or removal of remains will be WMuded deters a vMne s and will the done in p^vaq,with dignity and respect.
IDENTIFICATION OF DECFABED
Name Of�sed:Jennifer Lynn McKamon Mull Os McObtl
w,Known g m,:215 Goose Island Rd.. Argyle NY 12809
Plewd DeaM:, 215 Goose Island W., Argyle, NY 12809
Ee.: OM ®F lit: 38 008 OW2911982 Date doeeM' OW/18/1020 Esdmete]vxgnr
CmaipOM d we Ug Wisner In whom honest all be Yliw ,
Flberboardlaltemative wntainer, Mefthews Company
PERSON INC Ingr LOF OiS MON
X rn wfr of dsysRm,ynigr CNE of the causing;
I etWe ace Me designated agent of Me tlew»M designated In a will or writen 'mdrvme^t ezaNee punuem to Public
Huth Law Sacco^4201.
-or
b ere have no knowledge Mn Me mnemonic exeMW a wMten instrument transient to Public teats Law sermon 4201 or e
will bargaining dimensions for the uncommon of his ether remains ant has are me damemas)having pdmty under Public Heanb Lsw
$edm 4201 and have the dgM N aotens,uematlwd Of Me comment of the dewwm MylOur mid nshlp ro is daceaeW Is ee
dbn:
Jennifer Lynn MONemon
eaggir
DOS-i8 f(emu. 04R0) Page 103
Authorization for Cremation and Disposition
(i red hoar the Ha beawf
Nuwber'. 42 ceacripoon:Survivina Soause
1. A person designated in wraing pursuant b Public HN lw$ecbn 4201
2. The surviving stanise
2a. The sunrwirq Miami goner
a. My surviving Mil YpMeen were of age or older,
A Asurvirmg parent
& A SUNW9 III egblNn years of ape or older',
S. A unduly apWinlst guorclun',
T. My rMson(s)eighteen years of Age or order shaped to sham in the 6pel6 and who iWa has Mean in RYtrar N Pe accounts;
8. A di apparent fducary of Pe stele',
9. A At loan or Mann who haseaecNM a wagon solument punNm To Public Heats law Section 4201 O)',
10. A chief fiscal Mfiror of a county,or a public atlmnbinlor appanYd pumuanl btlw Suogele's Coun Provent M;
Wa. My chair person who is acting an Road of the acmasM and who has eveaktl a women aYlsoent pursuant W Public HNah
beer section 4201R).
nLL THREE of the h4dwrpl
XIA4e hereby affirm mat the bo]y of the tleceamb Moos nor wnYln a omen. banerypa'H- . poorer cell, realoXBve lmganf
or Mio.Mva arise sera mm env aucn nuleriaY inre nmavetl pier W its evNvilii Mmie aYNom.tlon farm. Fallure m remove
9eme polar nemmmin may result in Inrm W Me rnmMry and pnnulory ov reanrel.
XAce affirm con instructions have been given W SwaraaA. Phib
regeMing me removal M any peoemal pgreM or dMr thug of wave which any person sgning baker or aM femih memler MT The
dereased wiaMc to Panama. Pine View CrematMium
is ham 2aponaible for Me removal of personal Items kmn the condoner of from the remains of My de W. Pamnal Xeim YM In 1M
Ines or wIT me remains wllI be dn4oyaM br Me cmm=on process and canna ba rablered after nmremon.
Imo hereto aumomm Pine View Crematonum
newswires,
b cmeY Me remains of the Geeaud.
I ir IOPTIONA
III Mrebya haiw men b Idlreclor br dellr entl coma by ana
A al .XdNnNEn opinion of lu MrNbCa nd NY bmrb 0comgn
are
of such aXemM cremebry.
FINAL DISPO8RION
The pemn muffirrinabod W retthe me commits remYrn of He Answered from inn aematwy to
Name:Singleton Sullivan Poter Funeral Home Sarah A. Phib
Address: *Y7 Say Road, puaenebury, NV 1261 Phone (518) 193< 59
To aem.Ware rewmto kdemered vnllceaYpNts aNraWwe:
' To be eci tl to mily
HMaM oeuan mepoeon rened some dow not Wlm DoeeNaloratlW aamaM nirnms.
Pine View Cremaborlum Y aalMretl W 9he Nereasboa
Me remains W Singleton Sullivan Potter Funeral Home M tlNNxy
massin wreoi or by reglelamd mail. � Jennifer Lynn McfArrtan
D I Sgo-f(nev. Road) m.� Fell
Authorization for Cremation and Disposition
/// rgrenmwmy
y� y+y�Ym`�WYe unEenlvq Nat Ntlw remains;are cltloimN within 130 tlaya dcnmTiary
' Pine View Crematorium mq depose dire remaea in
an Ylederede manner.seal as W calddW. w.un.+uri
CREMATION COM]MME RN
(♦pdMy O.YE OINe bWwinpl
Singleton Sullivan Potter Funeral
M um to Ce used as a mMzinar IarIM csnedE mne'vu M1Ba Dean puiMeW horn 14mm
eM if6 AEe]uMhxa:
IMp understand!had if tlro an is too small WFOM the adds cremebE moral an M]ilbul Mid m lnr map,M wM M EINWIT
Mum 'm MyelpulNnatl. mNAFdan wffmumispuNaw ot1M pmon
Pine View Crematorium ad pair the damned random'in
nrnwmim
a hill summary containerbr calway
TM1l Aumonemon Fair sex amriaed by Sarah A. Philo wu emn,Wdd
Singleton Sullivan Potter Funeral Home
407 Bay Rcatl Cuaerrebury NY 12804
w�+hm.har.0
aM is ingrain W the Nmhal alrMar as mtlreae W inn execution.
INh haw recervad a mmpleleC way d N6 Aud onaNm Form.
( yndpslam
e ahas
tr shim "
this
tlsl
otM accuracy Intamaaon contained n MAuhastramonFurn and nMarg the
signsdlhla 19th rall September X20
Mann Scott MCKemon 'IY
M y"
215 C hue Island Rd Argyle NY 12809-
Maaa
snrms,w.. �•
WIINEas:
Sarah A. Phil n( M1 li /M1 `1Q t� Q
dr...ombmadnmma.m �6�
128a9
dennHer Lynn McKinnon
on
yraar
DOS-1e99-I(Re , MO) Pass 3 d3