Smagala, Richard Pine View Cemeter
Y & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL NoME: _ _ _
' RETURN TIME:
DATE A TIME REMAINS ARRIVED AT CREMATORY;
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS
uµ� t guLtL4�
NAME.
CASE A
TYPE OF CpNTgINER __
PLACE OF DEATH:
ESTIMATED WEIGHT OF REMAINS 8 CONTAINER_-_ 'I
PLACED IN HOLD: - -ZLEf
PLACED IN REFRIGERATION:
DATE OF CREMATION:
TIME STARTED: J']O ----
' y� IME CO ET __ 71
PLACED IN RETORT: 7i3a dIn
RETORTpIN WHICH REMAINS WERE CREMATED:
DETAILED REASON FOR DELAY IF REMAINS WERE C REMATERE THAN HOURS
II Npr1
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SMALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
Oep.F CEMa151e S
NEWYORK I Division Of DmspaxDF cmMETeN
STE;y !n rcz Pill,
OPPoRTUl Cemeteries shngmnPwnue
No*".NY I223MOO
n 1518r47416226
Authorization for Cremation and Disposition
This mzaNft Farm must Re completed and signed prior to delivery of Name"for mmetlon.
Cale', 0&2612020 Nomber'.
Cranawry Name'.Pine Ylew Creddeadmum
Address 51 Quaker Road, Queensbury. NY 12804 F11me: (518)741
CREM MN M AN IRREYERSIBIE AND FINAL MOCE58.
Cmrelgn is call out by two ng the remains carry deceaeM add the container holding are remaNa into a command Wmessemere
mi an subjected to IMense Mal and All TM M1M and tome will Incinerate eM consume everphing except bone and might,
which an all teat will M left Aar cnmatlan.
FNV'ng cremation, the mmeW will lake reormudle Mort to delays all of are remains and other mythical"in me wembild
damMS but some minimal dust aM residue WII lifty be Ito behind. TM uemalory had ll A permy Incidewll aM foregn material M1mm
and remains and Ito undulating and bregn mMnal MII be dispowd des Rgu,R by law. TM amounted remains all Ee mecMn¢ally
programs into small phormand placed into a deugnabd wmercrw um. Cre W minim gwywi an Polved until ne
Will hp N recognizable of Wegwl Umme
OPEX NO OF THE CONTAINER
Tree chematoly may only open are CoMeMer holding the uncremMed human remains in oinked urcumYan¢s such as to Confirm the
identity of tot dCIXaSed or to ensure that no malelal is erclosM which might inure¢mfgoyees colonel the charmory purely X
buman remains coot tlellverM In a occasions lcM1 t riot suitable for mmtlied such as ceremonial or renal caske.the
coMmtny will uln Mat the nmetem be movM Into a suitable suddenly bebre ittl Me remains.remains. Theopenilgofa
ntainer or the barefer or nmoYal of remtina All by conducted Woo a wM and vnll ow more In pnmqr with dignify and reaped.
OENTIFICATIOX OF OECFABED
Name of aced: Rlehartl Sarni X ll Stebus: Nametl
Lan hyrown Aedrea:6 Fox Hollow lane, Queensbury, NY 12804
Hare of Deam:6 Fox Hollow Lana, Que buq, NY 121104
am. ®N Or Ape: 78 WS OWN11142 mremmam: 08��Za FatimNBd Will
DpdmalsoonnIX uske�Y� Mimr In all remeinawi�ll MydeX:wef
\ 1 ITT\ � A�{�V. )(L/��
PE �7
fPorsm(s)in CwAol WdisµaH.vn, MMb10NEdtle/dbMy)
ecoom 4 420120+Ito desgneleJ yBMINMe deuesetl desipnBled in a will ww,HtM IruNreMeaeColM purwerA W Public
waM Law swddn .
OR-
C-RS Inge have no knowledge that the deceased executed a wrNen inslmmenl pureuaMW Pubic Heaah Law Sweden 4201 ua
wil containing someone for Me dispersion a his or mer remains and INed am the gwsmRN havuna onorlb under Public Hearer law
sedim 4201 and here Me night to aumonx uemal of he remains 0 me de . RylOur nlationmgp to Me de[easetl b AS
bllws-.
Rich;: SMeBdIs
se
DOS-1 fig&f(Rev. Moro) Page 1 03
Authorization for Cremation and Disposition
rinartaommaumhee)
Numtrw 2 Deri Wife Chdel S
1. A Person acquired in wring; pursuarltm Public H Mlaw 5wastro (31:
2. The surviving spouse;
L. lM suMvilg dorryal Partner;
3. My rurvrvlrq chi !n9Meen years of age or older.
L Asurvrvilq parent
F. AsurviNlp using eighteen seem of age or elMl
8. AI aWUlly spwlnted guemien;
T. My agreed suGhwer,yeen of"a or beer ended to share in tM"tele and who ivare deal In TAWW npm she decreasedI
S. A duty epmimed fiduuary of the funeral
r. Adow friend or re erewho has mxc a Wntlen statement purwenl To Public Heats Lax Section 0201n)
10. A land fiscal ofiwr,of O wumy or a public administrator appointed Wnoenl to the admgate8 Cut"Prn "act;
109. Arty Ober That who is acme m barren MMe deWedl and Pats has execrad a winner funeral puauBnl b Public pease
Iaw 80OIM 4201pl
hi, ALL THREE althe(Nlowng)
tf'5 Me her"al Mat Its bMy Mthe deceased does net annual a and" barely pack. Power Cal, eventual ImPlant.
or radioactive device act man any wCn malenals were removed prior to me royal dthis AutMr MMU Form. Fsilum to rxnove
areas Mars prior W cremvtlal may rasur in form to the cnlnalory and nemamry pananrel.
Ciii Me affirm that lnswcums Mva been giren m WendvM Bul'Cr
regard are mmoval or any paswnal pwi or gear thing of ways which ary perwn ugmry WI aam lamiy MMW a the
awarded wishes m paserve. Pine View Crematorium
rs na rewwelae mrmw removal dpervwlel Mma from me mmamwroifrem ma remalna brew d.aesea. Paraorml Mma Its In ma
wrrYlrwr orxM me mnalnw Mn M arvoyed q me cremaeen process one cannot M relriavq vMrcremeson.
lMrahemwaumomm Pine View Crematorium
rc�vn'.�. mcnmam ma remslrro erW decaaasd
di DPTONAL)
YWa Pat allMGMO are named funeral dlrwmr m pmvlde bar rNMary to and cra irman by an aMmam
apparently, IFdeemed auxiliary In the opinion of are funeral runway, and to amend This arm to pmvlde the correct rumor and
MdM$of such arwmam crematory.
FINAL PIa W MN
The person gladiatorial IO rvzlro ra sweats amen;M the demas ham tln aemalcry is'.
Name;Christy S ag
Addtxs: 8Fox Hollow Lane Cornea ury NY 12890. Phone (518) 79677W
The aemamd renans OF dweaNd"I MdapvW M as Mcang
M m r•AHldll
r kr.xy rwwn Me ryewn n.mer.bww doe0 ml mb weaeatlen M the aelnMd remora.
Pine Mew Crematorium ie wtdhrulaad mghe poeeeupnaf
"a"'WrAI
the remamsm Singleton Sullivan Potter Funeral Home gMlivery
Iwxx>°wro
Inpnwnorg Mid Wro 1. Richard Smegala
D051898 f(Mv.0420) Prga2 d3
Authorization for Cremation and Disposition
fiesidMa Mbwiv)
C ilS Hwe meandered that if the mein en M ashmal whin 120 Wye of uemelbn,
Pine View Crematorium m.r daWaed Me Mmne in
m lndde..d.n.rm.r.avmrhrsuladr2_ uO.wd
CREMATION COMAINEPNRN
(�jEl CNE of Me klbwln9)
Singleton Sullivan Poller
Pn urn Nbe antl eaewdelnrbr has vemedG mein has Ewn WnlineE M1om -- -
--
anaisaesallwaasf011ons
Me understand!that H has an is bo small b M1CM IN,Bide nmwle0 Maio.Ma MMOI NO¢nlanrhad to man M tlMisom
OR-
[�_MwniamlyetW lieseE. IM'e uMeleWMNdHre um'o gxdueM woaanieeproreN]
Pine View Crematonum wl dew the cM.Nd mama In
a�gMmWny wMWer far derey m..u�n
This A~Jusitlon Form wr po'adeO M Wendy M. Bulieh wn emenew at
Sirgkton Sullivan Potter Funeral Home
407 Bey Road. Que snsbury, NY 12W4
aM b aqM oy the Nnnl daadd as wtlreae bib execution..
IMb ham io'wM a amended Wpr of bs AulFO agm FOM
The p rmoMal IaenNlb4 Winne Who the Ponami i In Coned d dapnlNdh who Oy signing this AUWMaedw Form.aCeagai
n tM aavnry and comdelnwaa M am Informsem wnnNaO In MN AUMor6a some aM wulthemi the ftpOil
sgmosew 28th dayd August 20
Chnsry Smegela
6 Fo �
8 F Hollow Lena Cueensbury NV 12804
Seem
a�+a�rwe...er ardy M. Bulich
10441
Moment Smagala
pi..aasa
IDO -1866f Plan. 0120) Ppe3d3