Rivers, Leroy Richard Pine View Cemetery g Crematorium
Quaker Road
Queensbury, NY 12504
(518) 745-4477 or (518( 745-4476
FUNERALNOME; *kg-W
RETURN TIME:
DATE S TIME REMAINS ARRIVED AT CREMATORY; 11 NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
T.
--
NAME -. _ _ -.
LEVI'"R CASE IT TYPE OF CONTAINER: __ MSif — • II /
PLACE OF DEATH: Z eeLMO`J _ -id. yt, - J 6L✓�!E..__
R'44--_T-I�IV�' �Fi�_r7(p_ IZ9
ESTIMATED WEIGHT OF REMAINS S CONTAINER_,..
PLACED IN HOLD;
PLACED IN REFRIGERgTN)N /j
DATE OF CREMATION:
TIME STARTED: _ l-7o 1 _ TIME COMP6 E EI
PLACED I,RETORT $I IN WHICH REMAINS WERE CREMATED:—MOVED: Z4Da Zj
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN QB HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE
THE CREMATION Aµ BE RErANEON THE PERMANENT FILE OF THE CREM^TEgT.
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Authorization for Cremation and Disposition
Tina Accountants,Form most be compin.a and maned prior by Weii W reme Ins bar uommion.
DabGel2Nrzoro Number:
Crematory Name:Pine Max Cnmebnum
Mares:Quaker Na. Guonnnry, NY 12W
CREMAMN IS AN WREVEnIME AND FINAL PROCESS.
Cmmalun a rbutal out by playing be remains of the deceawa I the arlbirgr whand IM remains Into ttema4on cbemi whom
May are subjected b intense heat and flame. The Mal and flame will InclnerW and consume ewMmnp empl hone slid melel.
which •all Nat will P,left near cremNon.
Following...nua on, the uemdoly,will lake reasonable eTMs he memory,all o1 the remains and often material from the economy,
chamber,but some minimal dust and residue call likely be Iaft behind. The aemabry will mpemw Indented and foreign mebdel frwn
Mee remain¢and thetnadenbt and foreign roll rel be dlapmed oleo regured bylaw. TMoema4dre IMMIb mx anlolly
pulvercu elite al pieces and platedinn a designated mnbinmorurn. CmmMW,mainsgenenllyarepuMrO uMIno
single hagmant is Atcenlnhb as skeletal tissue.
OPENING OF THE CONTAINER
The material may onry open Me wntalrer holding the macaroni human remains in limited circumstances such as m confirm Me
identify of We deceased or b ensure that no msta semi Mich might injure empoyw or damage the crematory,pmped8N
human remains am deii,mi in a mnlelner whlch Is not si Star for cm Win such as ceremonial or mnbl crsM4 the
crommarks will rpulre Net the remains be moved Into a soluble mdainer h It MMM the mmalns. The ypMing de
container or Me"I or remove dremelna will be conducted debre awiherz am sill M dole In dwaay, with dignity and respect.
IDENTIFICATION OF OECEASEO
NamoINDmeewa: Ldoy Richard Rlwm MaM lSIoms: gradient
Last Known Address'. 2 Twncend Rd..Ha W.Near Yak 12818
Place of Death response Ra. HadbN, New York tt03S
So+: ® M OF Ape:66 DOa'.0612611955 gbdo«u:Ge'g 020 Esmmated Wwpn:21 sibs
O ptlan of yakepmMalnar In Mich remains vAI bs skiletal.
Matthews Cremation Case - Caldboarcl top? ptywood bottom
PERSON IN CONTROL OF DISPOSR ON
(Forsal"coned of dsp k"..BONE of Me ldbviug)
1 ant are Mar veagn&M agent of rho d aced designated In a will or mMn Instrument amended yMuanl to Fubo,
Hel Lear ,on 4201.
OR.
Me have no dmWedge that the dewasW mecubd a w,Mn Separation pumuanlb Public Health Law Section 4201 Ore
ha confiners material fish the cISMo tin of his he her remains and Mae am Me Feman(sj henry pdmhyuMer Public HUIN Law
Secdmr 4NI and have Me need auNWiY mmatM arise remains of Me do 85o . MyMur miflouhlpb Ns deceased Is as
fdm,m
Leroy Richard Rivers
DO 1M.f(Rev. 04120) Page t d a
Authorization for Cremation and Disposition
(1l hcm lea heWal wf
Number 3 Descllpllon'. ru
1, A parson designated in wlNlg pursuant to Public Health Law Spoken 0201
2, The Winning All
on. The surviving capped partner
3, My wrviving HAM eighteen years of age w ddml
♦. A Sunni career
5. Asunvving sAlnq eighteen years of age or older.
A. AlAwNlly ani inked guaNhm
T. My forscn(e Dhy n yeas of age or bear en0eed toshare In Pe estate ate who iNne[mast In rWwdAnsh1p to me rumored.
e, A duly appointed Wideary fthe ealele:
9. Acicse Mend or mlative who has executed a wrMen sMlemenl Name nt of Public Health Law SectioM201(7)I
10. AChiHhow officer of a muntym a public administrator appointed pursuant to We Surrogate Court Procedure AW,
IN. My inches ppnon arm'A=i19 on behalf of the de 5a and who has executed awM4n etabment pursuant to Pahlic Haalth
Law Sewon 4201pl.
(chi yALL THREE of My fdbprid)
@�WYe hereby aMrm tMt Me LCEV cltMdeweed has notmMeM a Wpery,betlery park,pwrermll, mdioacirve Implant
Onamoil lve devlm ate that any such malenala were removal error b fhe execution of this AUMahiMon Faro, palture to mmove
I�aym/ee dame poor to aamtlion may result In halm to cmmabry,and cm Mot personnel.
'
a� send aMrm that instructions have base dam toCaeeaMs 5. Mailq
regarding We removal of any personal property adher Nang of value which any"man signing below or any tal member of Has
dormul pulro usual Pine view Charwoman
ie not eyronsible forms removal of pesorel apma ram the mntamerol Ire one ins Mug deceased. Paton Imma Ill m me
Zmr swim the deadline will W deW lim nn ayed by ran uam"i pre add caot payWill after ammatlon.
Me hnNry authosi Pine Vow Cremall
mnwpv to cmmi the rsmeMe M Medameawl.
IandeOPTIOncei
Idea heresy euthi Ma named IWild answer to provide Mr Will to and cmmNlon by an M maw
erory. M deemed necessary In the spin l on of thes aline l d lmtlor,and as amend His form to al the momt runty and
of such alternate cremator.
FINAL DISPOSITION
The Wmon au Nora[M m teve the vemated remains aMe demased from the umrelcry 0:
Name Photon Fuel Home, Inc.
Address 68 Main S , Hudson Fall New Yad 12639 pyryy. 51117474243
The cranial remains of eceased will be disposed W as serve:
deemed M family
If for arty reason Me pamn named aWve acres nW Wks prom¢&on W Me mmMW Am lru.
PMesiear Crematalum ssuM[ Won aerosol of
Me remain to (daemon n(anen Fune Home.Thu
by"wary
F,vwnv�Minn
in prawn or by sight lmast Leroy III Rivas
DD3189Sdpars, IW20) m"¢ Page 2of3
or
Authorization for Cremation and Disposition
llniw Pre lodowingf
We uMerslanb that it Me remems are ad veil µ1Nln 120 aeya m mm ,
Fine view Caroni
u o'M may handed olive farmers in
an Womaeabla manner, Much as by saanenng. ""
CREMATONCONTAMERNRN
((iaga?ONE d the Mrowmy)
An um to on uaen No a moral im hie charnel remains has Caen purchased Man
and Is lewlMl as tdbv5:
MO formal Met i1Na umie ba small to hold thaentin temmed remains, anaddltlonanpMasneimtreybusadia li+wy,
OR�
wlAn um is not yet ptnfwael. IMIe central NM I no on As control oron4ress Fobbed
Fine New Cremation,a
MMr [amN MII one Me cnmeel nmaina In
e beach control wnoloaM IMNry.
This AUNortza0on Fail was povked by Gm S. MNIk waeauwleda1
CeMlon Funded Form Inc, wn+mrrsrwl
by Main St., XWson Falls.New gory IM39 uuM xasws
and is Mpned by Na Nm l dlreclor as witness to its exeanon.
IhVe Mw revival a nompeetl capy of the AMan iat io,Form
The persons) IdentlNel below boom Me wenontet In control of leposltlon, who by signing this Authmwbn Form,aft" )
to the avunry and combination M the Infomuibn wnmined In this Authorization Form and combat Me foregoing.
Signal this $ day of Augwt p 10
A✓,raQr�,F��
f�(J v� c'trr�s° 7yitdtts�� �ril�P
WITNESS'.
Cerebral S. Meille J�
14357 rwnvnewrnna pww mapwe
Leroy RicNN For
WesasM
OQ 1896-1`Ser Sr i Free 3of3