Curtis, Sandy Pine View Cemetery g Crematorium
Quaker Road
Queensbury, My 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: - ____ yy
11
8 . rS"" fe- - -._. _._. RETURN TIME _ _
GATE & TIME REMAINS ARRIVED AT CREMATORY:
NAME OF FUNERAL DIRECTOR OR RECRISTERO E RESIDENT DELIVERING REMAINS:
_ - TIK ...._-rP�Iu
--
NAME [�Nppyy _.
_CDRLTB CASE •V�TYPE OF CONTAINER kM I
PLACE OF DEATH: .
--ate-AT - --5'-... 1q_FP.__,51tn 7R8
ESTIMATED WEIGHT OF REMAINS a CONTAINER_
PLACED IN HOLO:
PLACED IN REFRIGERATION:
DATE OF CREMATION: _ � -'—'-
...
TIME STARTED: _ --TIME COMPLETI O: _ILA
PLACED IN RETORT: 0 —i �-
RETORT IN WHICH REMAINS WERE CREMATED:DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED_ _-- MORE THAN HOURS
FROM TIME OF ACCEPTED DELIVERY
MOTEL rx CREMATION REMATION O ..._ __
SHALL
BC RETAINER IN THE rexM ENTrREOr TnEEReMATORY
NEW YORR Division DIVISI Wmd mtatm
srFT[oF ON OF CSMMER1ES
°PPONi°"'^- Cemeteries
ssed
Norman, d(adrenal
was'mxnal
Zthorintlon for Cremation and Disposition
This AU Odzatl Form must ask completed and signed prior to danvary a Mains our cismanon.
Da te August 2(, f
loft Number IYI
Cremmry Name: Mm VMm CrMlatory
Mdr Ol auK ROM aummWr W12B Poore 518-14544n
CREIMTON IS AN IRREVERSIBLE AND FINAL PRO .
Cmma is Coed oN by placing the remoim of the dewaeed and Me conmider basing Me deal m or a vema4on chamber whom
task an M4er miMense bertend flame. The Matend BarniIncinmte and consume avaryMlnO eMsp1 bane and maul.
,death am all Pal will G Nfl after cremation.
Following cremation Me uemetory will Nice reasonable efforts to remove all of Me remains and Diner maMriel M1dn Pe dews on
chamber but swne minimal dust and residue will IIMIy be kM1behiM, Trachea lOry will sepa2M InNwnlel add tensional M1om
the remains and Pemina bl and Merge maternal Nil bedispObd Of as accused bylaw TheuemekdremeinavAlberwandicAlly
pulweress) IMo small parody and pleOsd Into a Ceppmbd commermum. Cmmated mnalm generally an Wlwrlvd unal no
eln0lefnpmenl le recaOnlupRuaMelahlgnua.
OPENING OF THE CONTAINER
The tharl may only open Me comemer round the unc am human remains In Vapor orcumstand audit as to confirm the
Idennn the aewawd crse around had no mutant Is museum whisch might injure employees Ordamagethe cAm emrvplopem. if
human remaaM an del"r In a aantemn whim Is net suNabk for cremation such as aemmanaal or rust askuh.drum
mr.mN gwill yawl that Me remains be moved late a suitable coMa it before accepts Pa remains. TMrpenirg a.
ndmeror Pe mwwfwmmmowl of emains all be coMugBd Wrong witness and will be done M prrvacyW dgn4andmX
IDENTIFICATION OF DECUSED
Name of°eceaww SawyCunle Mama SbW¢ rrOEN�tY �
last Known Mdrece 20 Hunt AN Of 5, Fort Edward NY 1=8
Rem MOUM: MHUMAWLota Fm1E M. NY12M
Six: DM El Aga.46 Doe: 04/06/1974 win 0 wm:082=0 Estimated veghr 400
Dramision of aekeVmnbiner M xfiM 2 aim ws W"i"K
Minimum Cremation Casket, Florence Casket Co. CardboardfPine
PEMN IN CONTROL OR D SPOS TON
(Pamsell In amnw Nd¢p. ,, added!ONE a me rdMmq)
1 a'Mhb are me do tyu.md agent of may deRewd deaiemted In a near Or"Man instrument emaled pursuant to Public
Health Less Section 4201
A/ INJa have no knowledge that lea deodaW Mwcu dI a hmRlen imbumenl purauantto Public Health bw Section @O1 we
will contalnlnparechons ter Me dispoeiriol of Me w Wr mnaina aM IMe am Me Pomon(s)having Morlly uMer Public He M Law
Section 0201 read have the eight to current uemMw of Me remains OIMa Wm *MurmlaaomhlpWMedowau Was
roalms:
Sandy L. Curtis
DOS18061 IRew. wrzM Pape 1 old
Authorimtion for Cremation and Disposition
=fican meanwbw)
Number 3 DesmpOUI. AM survrvine Mla eWM1ben dal.of We"Now
] i"e Panama m sending po9uem to Publa H WM Liew faction 4WI(3).
. g spouse
fe. TM surviving domestic Pander.
3. Any,w wing child Whilism whom of ape or older,
4. Ahavrving Pe9M
S. A screwing sl0linp¢qul years of We w ddxl
S. AlewNl"poinW puaofian',
]. Arry pe90n(s)elgMean yeah Mega Or Olderen4lkdbslure In me aCbb end wM1O iysre Cl0"st lnrebtianshipbmedewased'.
B. A duly appointed fiduciary of Ne Mb .
P. Adoe mend or lnla who have eKCutad a%added sentiment Women b Pudlld Health but Seabed 4201(7),
10. A chief firalOffice,of a county na public adminllandor appointed pu rude to Na Sumgsb's court Promal pro
10e. Any her perm what a acting on b~of Na tlew and who has charnel a vrtltlen instrument pNweM to intake Heats
taw Section 4201(7).
( ALL THREE Mme Mliewing)
INh lrereYeMm I M ,Mtly of Ne dereW QYe nN¢nbin a deans OSltery dock power call, ndcn Implant
or=foodl"throw and Nat any such meelMa ware remodel Poor ro the eheWron of Nis Aumwtlaa0'mr Form. Fellun to remove
N Poor to CNm"on may mull In harm W the Cremaery,and comment"normal.
INh elfirm Net In&ruNoni none Eeen ghenW Total Khmer rued cmn
mgaNing May rpr Mal"modal property cram caching MnFxwutll any mmn adding below crony family meni me
Mwaud wishes to pr9 " Mine coal C9matary
Y and mmonsidle MNe mmoaal of pdsOnal hems trdn my WIA MrIX from the remains ofdhe deceased. PononalMmelutlnthe
blmrorMN the remains will be Metmyed by NB cnmadon pros s and cannot as hatnWed after Cremation.
�( me Mnby auborls, PmeY Cmmemry F
to camels me mnslm of the dewweb
�M OPbONALI
Yoe hereby auborhe NB named funeral director My provide br delivery to and Conference by an albmab
admaery. If deemed necessary In me opinion of Ne fumml dlxer, and to amend Nle Iwm to provide the coma name and
dma M such alternate cnterna .
FINAL DISPOSITION
Tie panne authorized to mwlwe the aemeel Wool M the dace nmm the cremaey:'.
Name'. M9. Khmer Fumrld Noma
mdms. 82 Kmadxay, Fort Edward, NY 12828 Piny: 518-747%18S
�ciTh elM9maim Maeonae]wlh Ce al.W�a vIn� rohuvs'.
sr� ao Cr>�R. C��b1,E�
oar any reeam Ne perms named abTalme rgllWep[eNssiMl after amounted 9mam%
PIneY Cmm bee o as NssrknIX
chair l
Me remM M.S. all funeral Hare
m anq,yllyny
N damn a by nOlaWed mn, itiml L Cudb
DOS-1W61(Macy Nie5h Pregal
Authorization for Cremation and Disposition
fie rdrowinID
unda
ineifi//—Irnedary mrealuthe remains are not naimeewimm 120 aayamnem.eon.
Pine VSw Gnmerdy
isucnwOf may ai{ueo 0l the remains In
an implrva0k manner.suU as Oy 9�.
CR INEMRN
GONE of Me ldA or
�As um to be used as a wMainerW they adsm.W remains has Adyn Wbi 1RT
and 1s Masontown as follues.
LW.una OW Mn If the um I.bad small b hold has snore vamaW remelq,an aLdl4onm rgM MMddw they C¢Addbrdelrvmy.
w
An um is ma yet Wbiae.l IM'e understand that if no um a P"aw OTMhanv40 Paramie]
� PInaY C�analmy
Mil plena the operated MlOin¢m
e Ipq pmryrz ry xnbirer br dMMry
This Amdw m rcw Foram"a pro Wed by Todd G, S hnM "a amcN.d at
M.B. offer Forest hyne �navw»rwwl
Bt Bma]wry FM Edward NY 121
and l¢vprea Oy the funeral dtmetor as willow an M waoalion.
IAy Mw remii atamnOil Cray 01 may AUMorhrtbn Farm.
1111,panord¢I IdanoMa bsbw IMn M.par em sl In coMpl W dlspwltloq who by.tOniof the Authenticate And,am gsl
b Yen accuracy and mmplOWnw ofthe lnbmadon contained In this AUMenenbn Fwm and suModmn(s) 0lon001r .
8lpnad Me 2oM on OF Ngwt v20
VATNE%:
Tood G. answer b
QIA
11010 rrwwnxr..u.w umnam+ue
Sally L Cuks
DOS10i(Rev. 0M20) P(p 3 W 9