Coburn, Ray Fine View Cemetery 8 Crematorium
Quaker Road
Queensbury, Ny 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME:
EM ATORY RETURN TIME: ___SATE B TIME REMAINS ARRIVED AT CREMATORY:
NAME OF FUNERAL DIRECTOR ORryREGRISTEREO RESIDENT DELIVERING
NAME
TYPE OF CONTAINER H'A�[!T — - CASEN L(g
PLACE OF DEATH:
ESTIMATED WEIGHT OF REMAINS 8 CONTAINER
PLACEO IN HOLD:
PLACID IN REFRIGERATION:
DATE OF CREMATION; � --�—�--- -
_—__.____ LTD
--
TIME STARTED: �I
/ry � — — ---'�,Ua W.. TIME COMPLETED: ._._
PLACED IN RETORT:
flETORT p IN W XIC" REMAINS WERE CR
EMATED;
�� '
DETAILED REASON FOR DELAY IF REMAINS WERE CREMA An
MORE THgftS �'
FROM TIME OF ACCEPTED DELIVERY:
"OTC THE CREMATION LOG _.__...._.__ _..__.._._ CREMATORY.
SHALL xeTn:neD IN me PeP.nxeNTxT FILE OF THE ueMprPxr —
sEW male I Division of OF CEM"MIN
SrRROF OMawo ,C'.. ,Hol,
°"°"" NIy. Cemeteries alwaMmgtor,Ai
Tel„ :inQuz
31
Authorization for Cremation and Disposition
This Auagr ma Form meet be Core~ land Sigro enter to OMHery M remelne for cmnanon.
OW27/2020 Number: qj8
crematory Name:Pine Yaw CrewaWium
naarrr.51 Quaker ROAD Quearrsbu NY 128M pnme� (518) 145d0]T
CREMATION 18 AN IRREVERSIBLE AND FINAL PROCESS.
Cramabon a umeE did by gleans Me remaim ache tlettasM and Me connote,holding the Rmaine into a veme4on dumber xPere
MeynRsWieded ldWnwheMandflame. The MManOMmawlll lncMSmUaMo umeeve ingexdot eend 11*Y1,
whi are Olt that will ba Ina after crmrution.
FollaMng cremation, Me winki will m ressonebk eXorm to remove all of the remains and either maternal hem Me Pentagon
chamber, but some minimal dust and residuemill likely the left behind The Oemel will Separate inddeMel and turM9n mdedal horn
the remains and the incidental and foreign maWMI will be dlapsM of as required try law, The cremated remains will be rad4nblly
puNemed into small pieces and plamd Into a dMgnab mnWnerorum. Cnm$W mmalm Sanemlty an pulverlad unfli m
ha single m IFrecmirmabN anske lti m
OPENM OF THE CONTMNER
The chamatory half only ccen the mmdrwr holding Me unumM human remaim in limited crtumstanres,such ea to confirm the
idemiNofthedewa Oftoenwm MMnon nalismdme "d hmgMinryrtemlod sxdamageteuMatDryprcpgN
human remsina are delivered Ina container which IS nice suitable stonemasonry such an mre mltlw rental m.heh Me
mMrly will inconvertible thmelm b moved into a sutlable contalmr Won Ileccepb Me nmalm. The opening We
WnbinerorthetransferorremovalMnmaire MIIbe¢ dud b awhnnsaMwillbedone Inpnvaq.w dgniNandgq ,
IM"11F CATON OF DECc sea
Nameof Deceased: Ray Gotten Me" Btalue; Mafri9E
lad Known Address,8 Mountain View Drive, So. Glans Fells, NY 12803
plm d O ,Glens Fells Hospgel, 100 Park Street. Glans Falls, NY 12801
sew ®M OF Ape. ]0 ooe; 08/01/1950 W dD 08128@020 ESOMaW ipM. ayn
Ces "on dmMUV W,mr in"an remains wil b mmNd.
Corrugated cardboeM, Matthews Casket Co.
PERSON NCONMQL OF 00�MN
(Permn(al M wnlml d Wpos,1'm, mid DfNEdgM hbwp)
I amfNe xe Me desgnaMd agent dMe dlmenddeslgnaled In a will orwMlen inel,urreM executed pursuers W POWic
l.w inn riot.
ON-
gc " We m knowledge Mal Me decoamd exeWa a""an lns"mwt Partners Pubm Hea"n Law Seagn 4201 or
wAlcord JIM Irs tx We dingeilian d he or hear remains she lMe are Me radmeal having pnaXy under Public HmM law
sMSara2dl hrva Me nga to aNM1Dnn aem.r d Me reams of the deaawd. Nyrox rNanoroMp to the decreased ten
M"wq:
Ray Coburn
COS-18916-1(Rev. bi Page 1 Of
Authoriution for Cremation and Disposition
(Nasal hom Me Hsl CebvJ
Number 2 Desolptbn: S000S2
1. Apnson monitored in writing pursuanl to Pudic NeaXn Lax 3e tion 4201131.
3. The surawng around.
A. The aurvi domestic wnrer:
S. My surrinng child sackers years or age or doer:
t AauMNng parent
B. A surviving abing common"am daps or mar.
S. AlawluM BppdmeE pardon',
r. My pronal6l eipmeen"am Of pa or older entitled to snare in the estate ate xlw iMre W9a911n reobnshipb No Maxwell
B. A duty appalled Manuel Me estate'.
B. A down frieM or motive who has endorsd a wMbn statement pursuanl to Public NeBM LBW Simian 4201(7):
1g. ielfiwlolfmralsowmy 01
a public administnta appanted pursuant b To Sunorom8ConnP um M:
y peraonwbmddmg on benan of Me deceased and who hen scummed a when nothing mount to PelageNeaM
lsa' a201(1}
IMfkI Au 1NNE came Mloorl
affirm that the body Or the cannel don not coma a artery, deal pock. Wwer 2n, radiaudwas mpem,
tlewice all and any such maahahs were removed iiorbtie mccuron dMe AUMdha Oman Falluabmnove
(j �bme WcnmroonmaymubinMmrb Ma CnmeroryaMcrmulary "Mnn1.
S`W2e Mal msWtlmns have been g^mn to CassidyyVonnSttetllna
ording mmoval of any personate propeM w arm tMrp d wine seems my person spry baba/or wry kmy member of the
deceased wanes to Pmaem. Pine Value Cromabrium
M Ice mmm.l d penOnBl ipms can Ike maam.r snowiness,ti rem.lra al Me de¢»M. wmn.l Xxrs MII ten W
meror: mmYM min ba neutral by Me camel ancestor and cannot M mrchat Nbr cmm"Ore
y1Na yaumoriza Pine View Crematorium
ke~tlm to mangle Man nmabe ON the Monsanto.
(� Trost
1Me rain, school Me named turned director to provMe for delivery To and namatbn by an ader ate
sr«nrory, ndnmed necessary in We op.Ion of Mn Nnaml dbxbn and b amend ma from to Provide the correct nan and
ed a same anemia Cremal
FMAL DMPOSRION
The parson enhanced to amiss Na oemami remains of The Medical fian tie veinal Is
Name:Regan Denny Stafford Funeral Home Cassidy VonStellirla
Andorra: 53 Quaker Road Queeraburs, NY 121H)4 Pncns: (515)192-1114
Two demotem ddemnnn will ce dmP do bbrre:
Retum to fetniy,
NbaW rencn W Wear MmBd ebwe man MI M(e CcnenlaraftllBaOnaMf parsons,
Pine Many rndotaium dad wgNep0anamd
man naw.w
"Normal Regan Q m y Stafford Funeral Noma gdrv«y
kperem mby ogi.kmd mail. Rey Coburn
11)0S-18BB4 gi OW11) na Instal
A1411porintion for Cremation and Disposition
(]0O�i Mnb wnr2)
a uMenbM Mel I the rtmYm am ml cl irtc]adds 120 Wee Nfminat n.
Pine View Cremabnum may yypuawyle leineiro In
pw«eo..err
bh nnrvwr.euU es W x+Cnrvi9.
CREY M CON A NERn1RN
(fpq'MQHEGdanyom )
Regan Denny StsRard Funeral
M vn to no used as a wrMirerb the aemahp amine W been purchased beat u.....e
and is Eeavibed of Nlmsa:
e uMe tivl tltlw umhbo amelb noq tM"M amended ownirs,an ellE MW mMeircr my be coed for Weary.
6� dndwyatiouMCW. Wh uMaWMMdNM um is Wmtaeed aotlwrxiee govidM
Pine View Crematplum way plate they Gem named,In
a rapid hmWmrywnWnerla delivery
This Audprinaon Form wee ptoaNM by Ceaaldy Vonsteilina was seacoast
Regan Denny S1eRON Furwral Home
53 Quaker Rodeo, Queen dbury. NY 12606
and is a jnm by the final amaor a.rtreas to m emonam..
lMe here fawned a completed copy of Wis AaMwh.aon Form.
The p osonppdemMed below Ilan the pemi in control otdispxnion,who by sly;nine the A&MwIzaaM Form,an«qq
as The auurary and cwnplebnams of the Information shnhtned In Mh AUMantratlon Form and substitute)the brepoing.
synod Mb 27th dqW August 2ji
I
Berne Cobum ;�r(ti Fn CfdlsyLgrrl
6 Mountain Yew Dina, So. Glens Falls, NY 12ffi -
WIINEBs:
Cassidy VWSMM
137M
sesames
Ray Coburn
w.wa.�w
005-1awTow, 01R0) Pups 3of3