Cronquist, Davin Charles Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NV 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: 13 kA
RETURN TIME
nm t
DATE BTIME REMAINS ARRIVED AT CREMATORY. ,
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
_--
NAME: 'PIXyj, n (i�llts__ �rdAQltlSy 9(p(p/
TYPE OF CONTgINER:(�(ZLK S/[� - n� ^� T/
PLACE OF DEATH: _ Y J��''yI' b(I/'� ��� P �
ESTIMATED WEIGHT OF REMAINS 8 CONTAINER_
PLACED IN HOLD: _
—..
PLACED IN REFRIGERATION: ___
DATE OF CREMATION
TIME STARTED: _ _ _ T 10._yy� TIME COMPLETED:
PLACED IN RETORT _ �;..yOA0, _MOVED
RETORT A I N WHI O H RE MAIN S WERE CREMATED:
R E IRIS
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 NOUfl3
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE cneMATION LOG SHALL BE nETAINED IN Tn[ PERMANERr FILE OF TH6 cne IATORY.
nNow.Nmtasm
AfgHarizatlan for Cremation and Disposition
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This Autl//aoavation Foran muggbe doss9alaTadaaW slysHpNorb t(WvaryofymaNna RNbarneltlan.
thing, ' --up -lay Number "Nor
Crematory Name: Pine Ynew Cremalary
Address: Quaker Road, Queensburyflew York12B04 Phone: 5101748 n
CREMATION 15 AN IRREVERSIBLE AND FINK PROCESS.
Cremation is ortied out by placingthe remains of the deceased and the container holding the remains into a
mationchamberwheretheyar subjettedmintenseheatandflame.Thehok &mey linmwzat cvmane
everylM1l ng eaSaPt bone and meal,wMm art ap tlut wRl he left aher vanatlan.
Following cremation, the crematory will take reasonable efforts to remove an of the remains and Other material from the
cremation chamber, but mine minimal dun and residue will likety 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 refulred by kw.The
cremated remains will be mechanically pulvedwal Into small pieces and placed into a designated container or um.GemMtl
maim generally are Adverbed until an single fraalwt 6 recognizable as skekW Raua
OPENING OF CONTAINER
The crematory may only open the container holding the umcremated human remains in limbed urcumsoncey such as to
confirm the aemity of the deceased or to ensure that no material is emosed which might injure employees or damage
crematory property. If human remains are"grew!in a containerw ildi Is And sultable for vemadan suM as aceremonw or
Tema MSEN,the dematvy will repWre that she remains be mwetl into a subable mariner gelere N ac the rem &the
opening of a codes Iner or the to rimer i ct er or removal of remans will be condued before a witness and will be done In privacy,
with dignity and respect.
IOENRFICATION OF O1"E�CEASEO
Nameof Deceased ° s.�YT 1aS L{Dn�I cC7l— Marnal sta :msu_% ni'r:x+
teat lapwn nadreaa:aZ\
Piece oronom: G d.T Gl�c �0�1°�
sea: KM OF Pge: 'S (ADDB: CA/IRhdlus Oebof peam�/�3`�UEstimaled SUNghc�ol�s
0esviption of mskel/mmainer in which remains will be delivered
Cepreakided Cardboard Box with Plywood Starmark Made] 9 38808
PERSON IN CONORM OF 0ISPOSITION
Permi in condel of disposition, initial ONE of the following)
I am/We are the designatetl agent of the deceased designated In a will or written instrument executed pursuant to Public
health law Nation 4201.
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., I/We have no knowledge that the deceased exerted a written instrument pursuantW Public Health law Nation 4201 or
will containing directions for the disposition of his or her remains and (Continued door page)
Dwinel-claw.WIW em.aw®f -C laxio
l am/secure the airports)Wing priority under Public Health lawsection 42D1 and have the right to normally cremation
of the remains N the deceased.My/Our rNaDonAlp to the dernsed a as follows:
(IrtMhOm the fist Ybwf ,,,��
Number—Li- cnIscm. YV 0 ss=r
A person desgnatetl in wrap; pursuant PUble Heats law eaotrom 4201 (3);
2. Tlresurvivingspouse;
2g.The surviving domestic Farmer.
My surviving Crild eighteen years of age or other
Ll A surviving parent',
g. AwrvNingsiobirgeighM nyeamofageorola
g. A lawfully appointed guaMlan;
2. Any Fersen(s)egntean yearsofageorolerelNMec! W share in Meestateand whoidare cbeestin
relationship to Me deceased;
L A duly appointed fiduciary of Me argues,
S. A Goss Mend or relative who has executed a emblem statement comment 0 Public Health Law §4201(7);
10. A chief fiscal oMcer of a county ore probe edmmistraMr appointed pursuant M the Surrogate's Court
Procedure Act
100.My abler person Who saw on behalf of the deceaeM and who has eacuteb a written statement pursuant
to Public Health law§4201(1).
(1p�LL iXFFFOj LMJollawlnpf
.SQ I/We hereby affirm that the baby of the deceased tices not contain a hattery, assay pads power cell, radinalve
Implant, or radlwcties deice and that any such materW4 were removed prior o the execution of this A@lroneatbn Form.
Ptllure as reserve Neu Name Pear to aemmem may rewh In ham to Me cmutay and vmMt Para al
546y lMe hereby affirm that instructions has been given to asmuidrwmrmrel regardingthe
removal of any personal property or other thing of value which any Parson signing below or any famlN member of the deceased
sigmas to preserve. lcwwhvvo'*a Pine View Centel b no responsible for removal N Personal
Items Man the container or Men the remains Mthe deceased. Personal perm Past In the container ar with Me ramalm will W
destroyed Ica the aemelbn Probes eM nnM W reversed after amvrbn.
c I/We nxMysu[haWleem,wvm+zs a to aemrte Me remains of
the decrosed.
FINAL D SP09rrox
The person audutized td receive Me camaled real of Me deceased horn Me Paraguay IS
Name: H
Adtlreca'. .. 28g4 Phase: l")nl-g303
The cremated real of deseasttl will has disposed of W Midi
Neal.10 Mmity to ce deckled
If for any reason Me parson named above does bar take peamsaem of Me mareted hamaim,
(amnM,nxrel o C is autlKKlaed w give Possession M Me ranameb
pu e�ar,ammmel ^BakeF rat HD by delivery In pecom or by registered mail.
V L
oasLse..Paw.wnm
V ppggydaTwuwaN,
a_Rrok a mMatMMe remains ere wtca mad wiMin diooatof Me
Is�yt,� p� C M my dupOte of the remains in an irratievaEk manner,
sum as by scethMO.
REWTIONOONTAINFWM
IdissoNFOlde kowmP)
um to se used as a container for Me cremated remains has Caen Purchased tom Baker
Funeral Hone and is tlefcrated as follors:
INJe underetand Net if Me um b roo small a hoW the entre cremaaa remains, an additional nqk container may ed used
Mdeliverv.
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y5V�fn um has not yet seen purdnased. I" understand Net K no um a Purchased or mherwise Fmvtled lwwnawx
rests FlinLyies,O will place Me cremaaa remains In a ii tempoaly
wnain.rr«delixerv.
This&ahaMation Farm was PrOoked W Yim,,P as dawwl
Was atiamted at rI�mel 0 1
mama nwne aafesrl " streetO N Vark 120oa and is egnad by Me furrerel director
as witness to is executon.
MfOa have received a wmVaad copy of Mis Adhorite Lion Form.
The person(s)irlanhfietl below Patera the persons) M iX)dI oldlsposltlon, aMo by siriM Mis AUMorhetion
Form, stainers) a its sixurn dy andmmpleleness aMe sdormatoo edrainad in Mis Aulllanzatlan Form anal
authonze(s) Me forepoay.
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WITNESS �d8 OQ�
n«emicyanwrypCwM+Mxame haavWxaaa
Funkneri
H Ron III
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