Manney, Tiffany Pine View Cemetery & crematorium
Quaker Road
Queensburyl NY 12804
(518) 745-4477 or (510) 745-4476
FUNERAL HOME: yAp�A,gi
RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: -'lfj-7p
NAME OF FUNERAL DIRECTOR OR REGRISTEREO RESIDENT DELIVERING REMAINS
/ B _
NAME /..FFF4Y-i—wFAPq/.'Q J'11nM1X
_CASE tl 9� 5
TYPE OF CONTAINER: SI♦(� �.j._
PLACE OF DEATH: / 27 // / 2 u✓✓ Jam.. ,L�
�A4.cFn.. Rmc�-�'va/.++f4. N♦?til YiF /�N/y._.
ESTIMATED WEIGHT OF REMAINS 6 CONTAINER_ $
PLAceD IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION, C-Z(_pp Td
� J� �T.
TIME STARTED: /bpp / —TIME COMPLETED:
PLACED IN RETORT: / 3{ -
--�—Lfvl —MOVED:
RETORT IN WHICH REMAINS WERE CREMATED: _
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 43 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION $HALLBE RETAINED INTRE PERMANENT FILE OFTHE CRExcronr,
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STAI F K ON O ni 9m I
sTnTEOF Division Ot orvksloN OCCEMETsalss
° '°MNM Cemeteries 99
Press.qY 1333Y0W1
TNry ne 151%4ral
Authorization for Cremation and Disposition
TING AuW lmdon Form must be completed and signed prior b del went or remains hr emnenon.
Date:August 25, 21120 Number 965
Cr om Name: pine saw Cremebry
Amiga;21 Quaker Rwtl Ouemn& , Now York 135M pie. 514I45M77
CREMRTON 15 AN IRREVERSIBLE AND FINAL PROCE98.
Cremation Is gamed out by plating the remains of the dowai and the container haMbq the mmtins into nemabon Member
they are subjected to Intense beat and flame. The fleet and flame will incirxrate and consume ewrvMing manager bone and medl,
which am all but will be left after cremaflon.
elloing mmotion, Its vemacry sell Wera mble~a b remove all of the remand and Other malarial from the cremation
chamber. bud game minimal dual and resit r art likely be left PMlnd The crematory MII separate inadeMll and bregn materne from
the remand and the incdentel and foreign frati ial wil be disposed gas regueed by law. The mmaled remains mil be mechan'cally
pulverized Into aural Berea and Mal drM a dewank =Miner"um. CMMMdremainsgensmlryampulwi duntilrw
single hagmsM he mngniv bin as Audi dmue.
OPENING OF THE CONTNNER
The vemMory may oMy open the container holding the unaemNed human remaina'm limited drwmMnme, such as to coin"Me
Idal M the derea5 or to ensure Mal no mmena is enchmard which might injureemployees or damage the crematory prapeny. If
human remains am delivered In a Commairear which is not suMable far emmaflon such as ceremonial or mMal inkµ me
mrem.rory w111 regnire M.r Me remmm be moored inm a snidbk conbirrer befam i[auspb Me mmain.. The opening of a
Mamerm We transfer ar remove alremams wil be conducted before a Mtneas and Wu W done In pdveq,arm dignity end maned.
IDENTIFICATION OF DECEASED
Name of Declared!: TiXeny Memo" Mena Striae: il•Npelc4sl
Led Known Address'. 197 Louden Hoed Saral New York I?A 66
Plow of Datlh: 191 Lotlm met SSM"a, New Years 101.15,
Sex: OM OF Age: 39 Doe: 07-16-1981 Date m�'.08-3d-2020 Eagrnebd WeNM 150
Des Om OF akeVPo nN in Midi remains ad be delwM
Florence Casket, plywood corrugated cardboard wnreiner.
PERSON IN CONTROL OF OISPWMN
(Pe9M(af al :mi dN�idno, lnl6al ONE Nmg h M")
I amNJe aA the designated agent of Me dxeaaed designated in awll or miMn InaWment eaeMed pMun110 Public
Health taw 5emon 0201.
.OR-
CI li have no knowledge that the decreased evaled a adman instrument pursuant to Public Heats Law 5eclion 4201 of
gall coretaining maggots fair the disposal of his Or her remains and saw am Its genon(s)most priority under Public Heatlh uw
5etion 4201 and nwe Of Oil to auMarlsa oemaeon of the remains M Me Moment. MyNbur relationship to the deceased lam
%li w
Tiffany Manney
005-lal(Rev.Sol Page 1 of 3
Authorization for Cremation and Disposition
(hum them the ux below)
Numoer3 Oncnprion Any surviving child n00Npn years Of ages older.
1. A p9Ron designated in wool pwsueM M PUNIC Hei 18w Section @01(3).
2, no arousing spouse
2m. The arresting domestic paMerl
3. Airy surviving chill demean"am Napa s ok .
l Asurviving parent
5. A surviving sibling eighteen"am 0f age or older,
S. A hopefully app0imed guardian;
L Any peaonm )eighteen years of ape a older el ill aham in the estate and who lame cbsetl In Wagonship to the aemmuea;
B. A awry appcinted fidu6ary W Me estate:
ye. AgOae friend Or relarrve w8o has executed a wren statement pursuant tO %a C Heats LWs$aCHOn 4201 OP,
10. A chief goal spear W a county or public administrefor aPoorned pursuant to the 5urmgabt Court Prowtant Ad;
its. My offer person who is acting On Carl Ce the assessment and who has executed a wren salwnent pursuant to PUNIC Health
Lea Sommn 421
(BALL THREE mass Ishoweri
CMOW hereby affirm Nat the body of Me dexAsed deed me Wnmin and ry,No"pent, Power melt ra catlive implant.
or su ioa res device and gar any such returns were removed ani Me exewbon Of MiSAUMorizatlon Form. Failure io mnOve
Mitsui Name pdorto semaaon may real in harm below cnmatsy antl wma try perwnrcl.
ere ANe affirm Mat inaV p a have been given g ClaireC Kmmpka
regaMing the renwal M airy personal proper yorsMr thing devalue which any Much sensing passional family rremberof the
dereeHa wastes to prmerve. Fare Vim Crematory
m nW responaide IortM renrwal o(pnwral Mms ham Me comWner of the remains of Me da[eased. Pamp4l lame Ind In Me
cMNeinmprwMt nor remain.win a a.eNar.e q Nor cmmamn prawn antl canna a hevleved afN.nrem.ban.
CMMae hereby a effi a Pilot View Crematory
cur
m cremeM Me mmmna of Has a.cesesa.
MOM OPTIONAL)
IMe hereby augonze Me named funml director t0 prwlM bar Mllvery No and cremadon by an alternate
Centel if aeemea necessary In Ma Opinion ofMe Pomml dlxMr,and M amend this foml to provide the correct more and
aadMs of Such albrMte crematory.
FINAL DISPOSITION
The motion authorized to naive the cremNe mmeim Wthe desesed ham Me comatory're;
Name. M. C. Kill remains Home
Address'. I Main St. SCNh Gens Falls. Nine York 120W pie, 518-7458118
The sematea museum of aecoased will N e isms cal W as follon:
Rek W ore daughter Cargo Ma
If W any human the person named assure dealt Not News poswnlm W the sema remain,
MneV Crematory, neutfxx wgwpce ma
OmmmuM
Me mmems to M. D. Kilmer Funeral Home by defreary
in moron or by re0retemE met, n TWany Mal
DOS 1896 f May dead) nvane Pet
Authorization for Cremation and Disposition
bmilibde/Nloweri
cm limits untlerstand Nat If the remains are not chimed wnnn 120 data of uemaim.
pins Nex Central
aaE
an trreltlevapk manner, sueh MmeG�ann may impose M lM sensors in
SMl nnp.
D
BSI ONE in the bWvrvnd)
M urn to na uses as a container for the cremi mmaiu has been puMa Tom M. B. Klhrer Funeral Home
add is dear as tdb
RAd nominal The 6the um p too m04 W 11I this antis GemM d remain, as eddiaonal ngis mMelnv may be mass W dNrvmy
-0F
An um is not ford puMamd. IMb uMeslnid Mat tlro um is puMamd or d revess p'wv
Pine New Csmatpy
Mi pace Me csmesd remains in
a did h Wary container kin delivery.
This AufhWUMn Farm was annised by Clain C, Kmcpte was eaewlM at
R.wum.++rrw
M. B. Kilmer Funeral Mime
138 Main id South Glans Falls. New York 12803
and is srdnad Mthe funeral or tttor as witness to as easmorn au
V have mmirm a wmpleted used,of this AuthorlvYm Form.
The pmonfs)IdoMftd bNow Islam Me thermal in lobster off tlemica M1 who by signing Mile AOMor Um Farm,adopt
b Me accunay and completeness of to Informal cathedral In MIS AUMarhnm Form add auMrd colto brd inp.
Bgmd MIS 25m day a Ali TO
Caitlin Manned,
215 WTie El Ear Fad Ed n New YOM . RMA[[AA�ALL!!
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