Perry, Larry L. Pine View Cemetery $ Crematorium
Quaker Road
Queensburyl NY 12804
p(518) 745-4477 or (518) 745-4478
FUNERAL NONE: (,/-�� )i_ �
..'_-hurl
-- - _. RETURN TIME:
OgTEB TIME REMAINS ARRIVED � --"AT CREMATORY:
NAME OF FUNERAL DIRECTOR OR REGRISTERFO RESIDENT DECIDER" D �—
__
NAME /4Lhi__.?� q
TYPE OF CONJTAINER p� �- ,� CASE H / �y
PLACE OF DEATH:
E8rIMArED WEIGHT _..._—.. _�._.
OF REMAINS a CONTAINER-. V Ib
PLACED IN HOLD: ���'�'-----� _
PLACED IN REFRIGERATION; 1✓ - _- - —'
GATE OF CREMATION: —
-�d9-22ziz.—_ ----
TIME STARTED: _ 11
- -'-- - .TIME COMPLETED:
�D:{T��[[ I�PLACED IN RETORT: - - ---.
__MOVED:
RETORT If IN WHICH REMAINS WERE CREMATED:
DETAILED REASON FOR DELAY IF REMAINS WEREEMA FO MOREHqN VB HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE THE CREMATION LOG SHALLRE RETAINED
-R --.- -
IN TryE pERMAN ENT FILE OF THE CxEmgTORY.
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NEwYORK Division of
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Authorization for Cremation and Disposition
Thla Aurboniuman Form must be completed and signed paort0 delivery at remains percmnation.
Date.8272020 Number.
channel Name: Pine View Crematory
Quaker Rees, ouamabury, rvr 1Y@tq S1bT45.NTi
Atldreu: Pbx:
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cmmatim is fAnie!cut by placing the remains or the Marshall and the container hoairg the rem91r5 into Cana llm chamber xMn
Moves sugMed to manse heat and name. Tne na.tana name win gclrena aM cansune everyMlne.soaps bore aM meal.
which ari Futwgl be left a rcrc abon.
Following oe On.Me aammary will Wks reasonable Cborls W remote all of the and other materol have the oNM em
chamber. bud same minimal dap and resmuewil tlkay be left behind. T appealh pram wilesparatemddenalandroreianm enalham
then insand MemuaeoWlandfomgnmatedelvAlbediapaYaofasrequiredbylaw. ih¢Gemaaaremains vnll[e meMeniWry
puNedzed into smell pieces and Naretl into a designated container or um. Cnmsaa samaina Malawi ly am pulvarlvtl until ray
single hagment is numerical an smanal tlMuf.
OPENING OF THE CONTAINER
That mandatory may only Open the container holding the Ordeal human remains in limited tlwmsarK¢5, suM as W confirm Me
dents of Me mahmsed or to ensure that no material is parallel phial might injure minorities or"mass the crematory property. N
human remains are del mad in a conalrer which is not suitable for common such as ceremonial or Hotel enkN,ban
viral will promo that Me deal W moved into a suitable cartel before it accepts her remains. The opening of a
deal Or the transfer Or r¢mwal of remand Oil be canduetl belme a witness and will be done In above.war GgnM and respect.
IDENTIFICATION OF DECEASED
Name ofOeceaaed: Larry L. Perry Marlml Sawa: Married
Liar known Address. 141 Hollow Rd., Hadley, NV 12335
Pa of Oei histogram
se.: Elm OFi mi I 8Oef :8272020 esbmatet weigh 220
Description of caskev¢naner in which remains Ml be delivered.
McDonald basic crernalion contained, no interior
PERSON IN CONTROL OF DISPOSITION
(ParamlyMmMndaawosilbn. i=eel ONEdMa daWwingl
I analytic are Me designated agent of Me deceased despmeted In a art or when instrument¢s¢Cutea punuanl W Public
Heats Ww Samoa Q01.
OF
_L IMb have no
frtheleag¢theMf his or red awardedaM ended, Me parMpds) maing Pudic underhel taw Setlpn020t wa
ONtmnalni1 and
the
the tliaryeNonofbaorher Meaand ,0 am Me
mad. hi) hur Mornunder Pudic HeelO bw
S lhavar 301 and her¢the fight l0 audience aemetlm MMe remains Ol Me deceased MylOus relaNOneNip aM0 MuaseE IS as
ronow
Larry L. Perry
DOS4e96f IR¢v. 06115) Page t of
AutEoriration tour Cremation and Disposition
andal the awwHm
Fine bit VAR and WW that it nmyns are has blamed wilM1vi 120 days o'venetian.
may dial o1 W smears in
an immevaeie manner, such as ey scadaire. twin
9UMATONCONTAINE�
new ONE a the MlMringf
An um to be use as a mnlaioer for Me vamNed remains has been pumnasid Men
ant is desmYd as feel,
Fee undeTbnd that it the um is too Amall b hold Me entire cremaal remains, an additional ran withdrew may be used for adivery.
4ar-
C)v Mum is rM yet WrnN9ed. IM1VeundMe Wtt Hnournie PuMaseda Og9Mwpmvided
Fix Uew communist
will plead the cremaad remains in
M1oacwps
a rigid temWrary Osaaiar for delivery.
The AaMwlztl Farm was pmvtled M Patricia Miller was exeoneda
Brewer Funeral Home, Inc. «wwmw.Nw
24 CnVCti 6r, fake thRBme, NY 12W a+ws w"V
and Ie signed try the funeral dlo lm as address to ire execaidn.
I/We ham revived a compared copy antis Authorization Farm.
The panel Idarrufied below irai the Ponpnfe) in warp N dlepwition,who by signing Mis Amendment Fmm,Real
W fine umry MR Plabww of the Information waained in MM AuMMzatlon Farm and 2udrodzN9)Me forgoing.
eyrradmis 27 d or 20
ry ]o
Donne PerryU-�mA Q��
w>aw
tat Hollow Rd, Hadley. NY 12815
WITNESS: mo• rv�w �Iw.l
Fabiaa Miller
12465
Larry L. Perry
DOS-1aged(Rea.=15) Page 6of 3
Authorization for Cremation antl Disposition
Postal Me bare xnwl r
NumCec @ o.Pa.,, spouse
1. Alerwn designated In ending Wrswnl to Pubbe Hmrytl Law Ssym Ag,,gy
2. The wrvvirg alpaca;
m. The wnnmg domestic panreo
1 My iv svurviving Chad eght«n care of age a doer:
froe
5. Aurvwmg cold
9 egnlem years of age,or older
9. A BeardAIJY Immemorial 9ueMien:
]. Any pa ti oun)eteltria of M ape of doer eMAletlbahere in the estate ads who iyare W96el in relaSdnWll 10 the decaused;
9. A dose in orrelatiue Mee hap mflue aeculed a weaken slebment Wpuant to Public Health Law Sudden4201(]I;
10. A UM hand officer M a wunry Of e Wdic administrator lanberand Wreuant to the 5urto0Ma s Court Procedure Ad:
19a. AN Mlbr ceredn who is acting M hehaP of the dereased and who has executed a warden 6latemMl pureuanlro Pudic Heats laws lion a201(�.
FALL THREE&the bbw,4ngl
D IMb hereby affirm that the May Of to dew does net COMain a ba . papery back, power Cell, radimeCWeimplant
Or mongrel deaMA and Mal any such mMedab were removed prior to the execution MMis AuurorizaNan Form. Failure b remove
Made leg sPdafucmmd4 may result In harm1oIts Cnmabry and C1Bmaory p onmi.
Most affirm tat tribunal hove been Paeoa dlller
Meet b
regarding Me remorel aany personal poor a or dlrerlhing of value which any person l gal differ or any body mam>x or"
Pine View CRmalay
orientalwishes toIXeaerve.
re net residual for the remded of reradnaliMma M1cm the wmamer or from die renal as the de¢aaed, general items lM he Me
1> COnamer or wits Me rema lee will for de" 4MB cmnatlon Pm aM canner he nblaval after chnnel
07 NVe here Pine Yiew Crematory
ty auNarl»
m.�.wyxmy
b Cnmab the ramaim a MB deuvaad.
FINAL DISPOSITION
The pFwnaNlM2u to recein the demadtl remains of Me theories hgll Me Pemugal is
Srwx Funded HOmq Inc.
Ne re:
Mdreu: 2a Church St.. Lake Laerm, Nv 12808 51&5b62]H
PICnB:
The diameter mature
e�Of boosted
1 waawalle9 degve!of as bless
ftIw �� ,
�1� N T.�>ovs \
If be any,breach Me lerwn named aWved red pod pauuaun aMeaureletl remard,
Pine View Crematory
s BUM Wto three diquuil of
Me remains to Brewer Formal Home, Ift
tn.werw�.a.w by delivery
in peson Or by reglaprer mail.
Larry L. Perry
D013,1898-f(Rew. U115) mrnuo.� Page 2 of