Wester,Elvita M. Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NV 12804
(51 a) 745-4477 or (518) 745-4476
FUNERAL HOME: _ _—_lG)yMLQA<
RETURN TIME: A2
DATE fl TIME REMgINSARRIVEDpTCREMATOPY:
NAME OF FUNERAL DIRECTOR OR RECRISTEREO RESIDENT DELIVERING REMAINS,
._ .. _-_-ft — R"sMeft
NAME: ELYITft
ASEA _ - -
TYPE OF CONTAINER: c
PLACE OF DEATH:
ESTIMATED WEIGHT OF REMAINS B CONTAINER_
. .. ....Z30— . _� 27D
pIACEO IN NOLO: IF
PLACED _-IN REFRIGERATION;
DATE OF CREMATION;
TIME STARTED: ___ ro. A.y1
-"' '-�----��./}LI..—TIME COMPLETED: ,.ALA yM -
PLACED IN RETORT: —_ _1C_v}'bH ._._MOVED: ,__ - iczd�yy`Y--
_.
RETORT Y IN WHICH REMAINS WERE CREMATED: _ pAT
DETAILED REASON FOR DELAY IF REMAINS WERE_ _CREMATED MORE 7RAN 48 OURS IZry�1yl
FROM TIME OF ACCEPTED DELIVERY: _ . Ikon
NOTE: THE CREMATION LOD SHALL oe RETAINED IN THE PERMANENT FILE OF THE CxeMATORY
��11 oewnher,
mersuit.
— ] NEWYORK Division of DIVISION Oftit
oP "'TM Cemeteries do Washers";ae,iffira
T"OhInk
Authoriution for Cremation and Disposition
This AutMnnuon Form must be completed and signed prior to delivery Of remains arorcmuBon.
Dale: kats;. 28,21120 Number. •IbD
Crematory Name:nna^n Cremsbdnn
FGdmss_ 21 Ouaker Reed,Oudembury, NV 12EM p� (SIB)Moduli
CREMATION IS AX IRREVERSIBLE AND FINAL%1OCE55.
Cre Om is mrneel out by plating the remains of Ne Mmesed me May container Mijug Me remaiM into a estimation NYn0.v whirs
Brn are subjected N Intense neat and name. The I and Rvma will mcmmd,and consume awrylhme aacapt th"surd nli
which am all that will be left after cremation.
Faldnrg cremation coo oemelory will Mite reasonable Name b remove all Mine remains and other mml ll ion the uemsem
MemM bad same mlmmal bust and residue win likely Mlen Mi The chmaMry kill Sewrare mudental and for mormw Men
the remains and iM Incidental and foreign material w;u M disposed area emubM by law. Thecremeted remains ad cemshan"N
panel inob small these and pre led into a degraftN m ow Or un. Cmmbd rwr Sy lr am pulvMatl uMtlm
at right as records usable as$Mimi tNwre.
OPENING OF THE CONTAINER
The crematory may only Olson Me consumer adding the unaemaled human remains mIirstool unaMrcM, wT an to s mMa
sanely of the deceased or mensure that no meterlahs seined which might lrryure employees;ordamage Me emmakry pCpedy B
human mmatns an dWiv Ina container which Is net suitable for cremation such as wremalal or real uSk W
amatory sell reguim Malthe mmains bs moved Into a earl container before RvccapY iha remtlm. The cpenot;Me
mm [mrm Me handle or removal of mnainawlll M conducted beore a aimess and welt M done In street,wlO dignify and msp
OEM F CAT ON OF OECE.aSEO
F e& led: Error M nV Manuel S s:
Lest Known Address: (a& / TIP- 1. lild_{ 01 j;tr}l
PIaw MOeaN: saraltya Hmpod. Berabga SMlnos. NY InW l
Do, Ok RIF Age'. 1E bi ta1M10M Oa oM . Ov2Sk2MW EMmabd Vidghti his
DacnpMn N CeakN/ finer In wheCh rename willed delivered.
( ryWma allmw.eVmenuwo MdM lwmMN said CvdbrmN CremaMn Container
06PO3111ON
(Moscow ascaabN W d'scosAon,All ONE time Idmwugf
I amdVe am Me designated agent of gw dereeaM Mitchell M a will or rMXn instrument miealed Olon ito ruble
He laws on 4201
OR
Me have 00 knowledge that to d IMI executed awritten imWment pureuant In PW'p Health law Damon 4201 or a
wan comet nine directions to Me dupceNon Mhis or her ramwm add led are the pvswt(s) Mon MmTy under Public HmM May
Met 4201 and have Me right to a d me cremation of the remains M Me demanded driller MMoMhlp to the deceased is tie
fellows
ElM M. N4dter
DOS-18984(Rev. O015) Page 1 of
Authorization for Cremation and Disposition
(Asset man Me list ndow)
Number pe5cry0on: slm'nng spouse
1. Aperson antipodal in MRtlrg paricam to Public He9M levy Section 4ID1 gal.
3. The sur ing areas
A. The survn'i no earned"Man
a Any scanning child dMf years of age or Now
AL A slurrying Parent.
6. A surviving hang eignhen years of age or clean
6. Ala lryapMimea guardian:
T. My PolaMls) agacen yawn of age or older enMletl tO Name in thin sandy and v.Ta lfrom named l n lela0ership to the aecomea:
S. A duty ap{Umea fiduciary of Me sal
9. Aclose Mena or relaive who has e•eecand a wrNan statement Teri to Public Health taw Section 421
10. A Mid Peel officer of awmy or e pudic admmslreM aMombd WrWem to Me Surrogate e s Court Procedure Ad
10•. My Met person who is atlmg an eR Of the deraasad and add tad"Wx W a written statement pursuant b Public Heath
tan SeNon 4201(7)
� Art ALL MREEMMe Mmvm g)l
�/
/l. L Me hxeby office Met Me body 0Vb electoral does not Conan a mother, battery Mad, Mover call, ddioacave imPlent
or radessoveM ire and test nor such mdeads acre removedpwb Meeraddern dNis AONo/tr Jon Fomr. FWIunb M1move
Nc�.(a�N/xn•pair b cremetlon may mull In IrmmbNa wmvbry aM cnmebry Poreonrrel.
�2f ' Mae afire NBtivmr doN have Ern grand to ROEYl 1. records,
responding The rammed aany descent contrary Or other pang of value wrtiN any Person s gmer;baser or arty holly member of V9
Moderated words m pesem PmeNew Cremeknum
rs nd rataMnsiaeMme removal of Mrnrlat lmme ricer Me aarmlMrm tmmmam Me remelns nrmn aeceasm. Paraorr.lwm•tnnln are
consumer of Me remains sent be aaMyed by Ne uamabon process and rennotbe rebtwea alkrcremman.
xbMi M homy warnings Plnevww Crcm um m ai l
b cAmab Me mmina of me decreased.
FINAL O9PofiITION
The person adlmxea in marine the aemdea remaPm al Me as may'nas aemmry tat:
Name: order I. Demands,
Address T Shaman Personal Ccndh. NY 1= Flpne (510)B.A` i
The matad mndns a of aMarmI wil be denies iMMn'
pek,,,.._.L -L— Breti
If fro any rc The Pmam renew¢box aces naYMfrmemeaal Mfor Miami estimate.
PlM "Cmmdarum Is standard to give Miseevon of
the ramvm to Dworman Funeral Home, Ined
ea.+�xew by aeuvery
in perm or by Ng'dad dmaid, Byron AL Viasta
r a a
OOS1W&IIRev.[1I15) Pa¢ ] N]
Authorization for Cremation and Disposition
Al�homemade)
Z uwe umemMnd"ume remains are mlcNlmed wnnln uo dW$a uemWm
Plmvlm cra"Worlum mv/maWxoitlw reu+ne In
n
an imemavahm manner win as M evlNnry.
RLY/rToNCOHIAINE_ BIN
BONE mtln hWwM91
r-�M win W be used ae a sombearear bar has command rpnalm SY Nan WrMnea]from Densmore FUM'N Home. M
eM Is described as felease.� i'✓,J+ s
IMh uMratand that if the un 'u too smell m ache the Ear c ramna, an a]ENwwl reed aoWrrer they N ux]her EMrvery
M
MumlenWy Wmhnaed. I uM dV dMUM4Wu aoN mpoNYd
P5nu1M'cltlMlMum call p4m IM UBmatM remains in
nnpNbmpmrYaAtlmrla CNlvdY. w..acernf
ThpAUNwI+Mbn Form was povMedW RCUrI - �� n.wuuv-x.�o was executed at
Mnemon Furness Hone. Ira.
n...rmwam
Sherman Avenue, Coimh, W 128M
and is stand M the mneral dlremr as amnia to he Weemon mvun
li have resonant a Completed copy of this AmMrleatlon Form.
The
saN � tn contral of eW lathis A steamboat lonst. mlel
dmecourFrynd cmM a the Of contained n NbuMmae Formnd nonreaders)me fore9olnt
SlBned MW 25m day of Aqus1 .m 30 —/
Douglas woater
�r- rG. n11 a 8a�-
ai�
w :
Robert bertI
1. oenemen
ioe+o
Efrp M. Wesnr
Oo8-18061(eve.�'15) Pa9e3of3