Burch, Wayne Clark Pine View Cemetery & Crematorium
Quaker Road
Queeesbury, Ny 12884
(518) 745-4477 Or (518) 745-4476
FUNERALHOME: . _�`Ay� _ --
M RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATOR V: /1
._bIlD
NAME Of FUNERAL DIRECTOR OR REGgISTERED RESIDENT DELIVERING REMAINS:
NAME:
CASE
TYPE OF CONTAINER;
PLACE OF DEATH: ..._-._74 (faRD
ESTIMATED WEI DHT OF REMAINS 6 CONTAINER,__.
PLACED IN HOLD:
PLACED IN REFRIGERATION: __ - - -
DATE OF CREMATION.
yq 91n a
TIME STARTED: �9D Ahl TIME GOMPLETeM ___ __R__
:SD
PLACED IN RETORT /I �p I,.�
1-4e I• F.___ MOVED —
RETORT & IN WHICH REMAINS WERE CREMATED;
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE -TH=p�N�q-S�NL-DUgs
FROM TIRE OF ACCEPTED DELIVERY:
NOTE: THE CREMATION WO SHALL DE RETAINED IN THE PERMANENT FILE OF THE CUEMATORY.
Authorization for Cremation and Disposition Nor a tars
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Thas AaaMpdxa Famf mustee pongdwwd a slPWPfor ED "Fal of re 8tw daNNatlpn.
Dale: 0 170 Number H--k
Crematory Name: mmy Cem "
AEdregs. Quaker Road, Oueanabury, New VOA l2 Phorre: 51817A5d977
CREMATION IS AN IRREWRMBM AND FINAL PROCESS.
Cremation Is carried our by placing the remains of the deceased and the mmainer holding the remains into a
cremation cla mberwherethey are subjected to intense beat and flame.The And and game will IMnerrta add mmume
eveDRBIr4meapt boa add mehil,which And all that will ber left after cm Qom
Following cremation, the crematory will take reasonable efforts to remove an of the remains and other mustowI from the
mosm chamber, but some minimal dust and residue will likely be left behind.The crematory will separate Incidental and
foreign material from the remains and the Incidental and foreign material will be disposed of as required bylaw.The
cremated remains will be mechanically Fulveried into small pieces and placed imoa designated container or um.Decreased
remains generally aft pcvedred until no Angle frapnenas is re[gpduble as skektalttsrN.
OPENING OF CONTAINER
The c oratory may only open the container Falling the un-cremated human remains In limited circumstances, such as to
confirm the ideaity of the reamed or to ensure that no material is enclosed which might injure employees or damage
crematory pmperry. If human amount am"burned in a de winds which is not subable for crcnWpn sush as a are ndNsAIA
rental cal theprematary will require the the remains b r moved Into a raiable romalne before it saepN the rentalns.The
opening of a container or transfer or removal of remains will be conducted before a witness and will be done In privacy,
with dignity and respect
IDENTIFICATION OF OECFASEO (�
Name of Deceeded,�PV� /��+ dyy-% &K-3k Mwft%I51ahm:YvhMf4?A
Lert Known Adtl^rae,a,:.Cyr o °yp y NV Yk?66
Placeof Death:
Sex: XM of gee: l Doe o"1�J,(, � 15U6 wreaoe.m: c�B JS ank€aumamdwaism:27L6s
Description of asked/mntalner In which remains will be dNwered:
Ophrudipted Cardboard Box with Plywayboo Starmark Model N 388M
PERSON IN CONTROL OF DISPOSITION
(Parder(s)in central of deposition, initial ONE of the following)
I am/we are the designated agent of the deceased designated In a will or written instrument aeclated pursuant to Public
health law settbn 6201.
-OR-
e have ro knowledge that the deceased executed a written instrument puaWnt to Public HeaIM law section 4301 or
al I canWining direction for the disposition of his or her remains and (Continued next papal
1>BYk� a"a
a,teaaaalan m,Nl a_, Pal
I am/we are the persontu)having priority,under Public Hearth taw sea ort 4201 and have the right to authorize cremnbn
M the remains of the aereasea. hismurrNetlomMp to the dertarad b as follei
nmentmm me no (mash o((ll
Numb¢ a conscription'. lJ 12
A ndesipnatetl in wrong NarrowedIsPublic Heats lax makint 4201 (3).
The summm spouse:
U.The surviving domestic canter',
3. Any surviving child eighteen years of age or older
4. A surviving parent
S. A surviving sibling eighteen years of age or older;
S. A lawfully appointed guardian',
T. AM peesonts)eighteen years of age or older entitled to share in the estate and who isdare closest In
relationship to Me deceased;
g. A duly appointed fiduciary of Me estate:
9. Aclose filend or relative who has executetl a written eratement pursuant to Public Haalth law §4201()),
10. A chief fisml officer of a courtly or a public administrator appointed pursuant to Me Suaogate's Court
Procedure Act;
IN.My other person who as acting on behalf of Me decmeed and who has emecNed a written state MWrsuant
to Public Hearth law§4201(]).
gain InFFFo/rlremessmrpl
I/We hereby affirm that the body of the deceased does net contain a battery,hsttery pad, ywer cell, radioactive
imp M, or radioactive device antl that any such materia6 were removed prior to the execution of this Authorization Form.
Failure to remove these arms prior to oematlon may muN M harm to the crematory and crematory perearmN.
\/� I/We hereby Watch Mat instructions have been ghren to(Hmmr +en ,mmel CaubaoHercr A141W regandingthe
removal of any personal property or other thing of value which any person signing below or any family member 0 the deceased
wishes to Preserve. rmmemrvmmel Pine Vkw Crematory is not responsible for removal of personal
hems from the container or from the remains of the clereased. Permnl items set In ow consumer or with the remalm will he
destroyed M the omutbn massive ant®nmt be marketed after aawibn.
I/we Forcer authorize Nmumrmml C marinate the remains of
Me aced.
Fi uDI S N
The Person auVwri sed to mammas the channel cM6ins 0Me deceased Rom the crematory Ia:
Naw'.
Addition: I I I shaveafte Street Qualsonsibury New y rl 12a" Phow (518 761-M3
The crewtatl rerrwim of deceased will bit disposed of as blows:
Realm to Maury to ce decided
If for any reason Me person named above does not tale Dosses%Ion of Me cremated remains,
(CwwnY wry P' Y L re authored to give Wessealut of Ms response
MTanmmm,e Bak F erw Hom by delivery In person or by registered mail.
L )N inn a, An
n
oarmali luv.n4101 rumrY
• (Ip)(j11rM frAbwNg)
IMb understand Nat if Use remains an rot Wined within 130 eaye of orientation,
m,4°.m.l Plne Yaw Crememry may dispose of Me remains in an iMetrievabk manner,
such as by scattering.
CREMATION CONTAINEFM/RN
(Ip, fMEofthefol ,n)
i
A� An sm m be used As a oxim nter cremated!rthe crena remains has been purchased from Baker
rsl Homo and is described as follows'.
IM/e understand that if Me um is but small m hold Me entire cremated remeins, an a]dilional rigs! Consumer may Gun used
for delivery.
-OR
_An um has not yet been purchased IMIe understand Mat a no um is purchased or otherwise provided fwwwo y
.°wl Pine Vew Cremamry will places the cremated remains in a Nat tempdrzry
container ford livery.
This Authorization Form was provided by r/wrimdmrw.oire) aid i10
was executed a[IMewMmeimmel
Aiwww Assam) 11 Larminefter threat Queentibmi, UM Yorx 12804aim is signed by the mMrll dbanor
as wimess to is executlon.
IM4 have received a completed copy of Mis Aumor'izati Form.
The persons) Aluminum!below ii the persona) in combat adirsposi0on, who by sianifg this Awhorizabon
Mc m, atksi to(Ire accuracy and commandments offlre information curtained in MN Authorization Form and
auprmhe(s) Me fundament.
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Amw°
raiMMONA,xi Missouri
WITNESS:
c ReBeM I f.A (�y
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