Brown, Bonnie Ruby Pine View Cemetery & Crematorium
Quaker Road
Quee"5bury, NY 12804
(518) 745-4477 or (518) 745-4478
FUNERAL NOME: �zzaL
RIVE 99. RETURN TIME:
NATEBTIME REMAINS ARRIVED AT CREMATORY: . ry �'L� -� 2 70
NAME OF FUNERAL DIRECTOR OR REGR STERED RESIDENT DELIVERIryr� NS.
�J .c
NAME 30n �
, CASEff TTPE OF CONTAINER
2Fs6({FyS� F C)�e,�fp� �. <�4e%4y>P /�(lAm�i3.lbt
PLACE OF DEATH: .55
ESTIMATED WEIGHT OF REMAINS A CONTAINER__ / Q
PLACED IN HOLD:
_... __PLACED IN RQFRIGERgTION: .
DATE OF CREMATION: _
TIME STARTED: 7;)ARyI -�
-"' -- '{ TIME COM L T O
PLACED IN RETORT "�. AN
- , 11 / MOVED
RETORT IN WHICH REMAINS WERE CREMATED:
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATE MO -�
FROM TIME OF ACCEPTEO DELIVERY: MORE THAN 4B NOUNS
NOTE: THE CREMATION LOG SHALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
Authorization for Cremation and Disposition ""DY,OI�O:'m;,„':
One CMMO"now, as we.hmsmo
Y 12231
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This Aulhgo'r/zadw Form mustbe somplmedandsignedpdurm "Ami terminalrub cremad n.
U Date: ZtF ZOZO Number: 9t07
Crematory Name: Pine View Crematorium
Address, Quaker Road Quirina ry. NY 12804 Phone: Sip7NS4Y77
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation is camel out by placing the remains of the deceased and the container holding the remains into a
cremation chamber where they am subjected to intense heat and flame. The heat and Dame will Incinerate and
consume everything except bone and metal, which are all that will be left attar cremation.
Following cremation, the crematory will take reasonable efforts to remove all of the remains and other material from
the cremation chamber, but some minimal dust and residue will likely be left behind The crematory will separate
incidental and foreign material from me remains and the incidental and foreign material will be disposed of as
requiretl by law. The cremated remains will be mechanically pulverized into small pieces and placed into a
designated container or um; Cremated remains generally are Pulverized until no single fragment is
recognizable as skeletal tissue.
OPENING OF CONTAINER.
The crematory may only open the container holding the uncremated human remains in limited circumstances, such
as to confirm the identity of the deceased or to ensure that no maenal is enclosed which might injure employees or
damage crematory property. If human remains are delivered In a container which Is not suitable for cremation
such as a ceremonial or rental casket, the cremabry will require that the remains be movetl into a suitable
container before it accepts the remains. The opening of a container or the transfer or removal of remains will be
conducted before a witness and will be done in privacy, with dignify and respect.
IDENTIFICATION OF DECEASED
Name of Deceased: Emmie Ruby Brown Martial Status: Manied
Lest Known Address: 132 Maple St. Hudson Falk New Yak 12839
Place of Death: Saratoga Hospital Szrmoga Springs New York 12966
T
Sex. M �/ Age: 62 DOB'. 08/31/1957 DateofDeath: 08/25/2020 Estimated Weight Ofti,
Description of casker/contamer in which remains will be delivered: Matthews Casket Co. Connection Case
Cardboard top/ plywood bottom
PERSON IN CONTROL OF DISPOSITION
( enswits) in whom of deposition, Infidel ONE of me Mbwmgf
I am/Vve are the designated agent of the deceased designated In a will or written instrument executed
Pursuant to Public Health Law section 4201.
A TTr�
�INve have no knowledge that the deceased executed a writen instrument pursuant to Public Health Law
etion 4201 or a will containing directions for the dislocation of his or her remains and (Conmoad newcape)
Bowie Ruby Brown
w,,.moev.m Pral
,J ant ya are the persons) having priority under Public Health Law section 4201 and have the right to authorize
cremation of the remains of tM1e deceased. All relationship to the deceased is as follows:
(li hi metier bemw)
Number: 2 Description: Husband
1. A person designated in writing pursuant to Public Health Law section 4201(3);
2. The surviving spouse;
2a. The surviving domestic partner;
3. Any surviving &no eighteen years of age or ostler:
A A surviving parent:
S. A surviving sibling eighteen years of age or older
S. A lawfully appointed guardian,
7. Any person(s) eighteen years of age or older ended to share in the estate and who is/are closest in
relationship to the deceased,
S. A only appointed fiduciary of the estate:
8. A close trend or relative who has executed a written statement pursuant to Public Health taw§4201(7);
10. A chief fiscal officer of a county or a public administrator appointed pursuant to the Surrogate Court
Procedure Act
10a. Any other person who is acing on behalf of the deceased and who has executed a written statement
dominant to Public Health Law §4201(7)
ddNgf ALL THREE bible fslowrng)
JILtp IAWe hereby all that the body of the deceased does not contain a battery, battery pack, power cell,
dma vie implantr or radioactive device and that any such materials were removed prior to Me execution of this
Authorization Form. Failure to remove these Items prior to cremation may result In harm to the crematory and
crematory personnel.
Me hereby affirm that instructions have been given to Cassandra S. Maille
ending the removal of any personal property or other thing of value which any person signing below or any family
member of the decreased wishes to preserve rmmavo,isse; Pine View Crematorium is
not
responsible for removal of personal items from the container or from the remains of the deceased. Personal items
left in the container or with the remains will be destroyed by the cremation process and cannot be retrieved
after cremation,
ccare�mation,
q♦.,I]� IlWe hereby authorize lmmmmr�mm.) Pine View Crematorium to cremate the
�� of tM1e deceased.
FINAL DISPOSITION
The person authorized to receive the cremated remains of the deceased from the crematory is:
Name'. Carleton Funersl Home, Inc.
Address: 68 Main Street, Hudson Falls, NY 12839 Phone: 519-7474243
The cremated remains of deceased will be disposed of as follows:
Burial at Gerald B.H.S. Sams National Cemetery
If for any reason the person named above does not take possession of the cremated remains,
(c Wcvyrene Pine View Crematory is authorized to give possession of the remains to
A�wf hmm nwml Carleton Funeral Home. Inc. by delivery in parson or by registered mail.
Boards Ruby Brown
Dosinsa4laev 01110) NemaorDwWhd Fall
��Ihe Iallovnng)
NJe untlara[antl That iF the remains are net claimetl wAhin 120 days of cremation,
ervn..,el Pine View Crematorium may dispose of the remains in an ivebievable manner,
such ea by scattering.
CREMATION CONTAINER/URN
(Mli -al ONE of Me fftwmg)
An um to be used as a container for the cremated remains has been Wrchasstl from
Cannon Funeral Home Inc and is deacnbed as follows:
If We understand that if the um is too small used for delivery. to hold the entire cremated remains, an additional rigid container may be
O
�An um has not yet been purchased. IfVJe understand that 0 no urn is purchased or otherwise provided
memn^emw Pine View Crematorium will place the cremated remains in a rigid temporary,
container for delivery.
The Authorization Form was provided by (Awm+aaemr,aml Cassandra S. Maille
was executed n romnw sw,n.mei Coleco Funeral Home Inc
(fune,wnem.awmsu 68 Me a SImeC Hudson Falls, NY 12839 and is signed by the funerel director
as witness to its execution.
We have received a completed copy of this Authorization Form.
The parabola) identified below isfare the person(s) in control of disposition, who by signing this
AUNorization Form, steeds) to the accuracy and completeness of the information contained In this
Autharintion Farm and authorize(s) the foregoing.
Signed this 26 day of August 20 20 .
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Address
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Address
WRNESS:
Cassandra S. Msille
Funw.ro.enmrrxwewrixnexwm rw,wo..wwap,N,e.
14257
wgwnxon rAmiee.
Bormie Ruby Brown
Due age as, 01110) wmeofVgxwmd P"303