Whitehouse, Jane M Pine View Cemetery $ crematorium
Quaker Road
Queensbury, NV 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: _ ____ . .-... . CU -
fA -_._..__... RETURN TIME-
DATE B TIME REMAINS ARRIVED AT CREMATORY: SLzr 2,'A
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS-
NAME: - HCk Uuao/us'E
TYPE OF CONTAINER {/_VWQ_ (4D�
PLACE OF DEATH: W lv€d� (Iry
ESTIMATED WEIGHT OF REMAINS 8 CONTAINER- _ R6
PLACED IN HOLD; - --_ —
PLACED IN REFRIGERATION: ,,_-,_ �I —
DATE OF CREMATION: L
TIME STARTED: _, 0 7zpl4 r ----_-.__TIME COMPLETED:
PLACED IN RETORT. _JI )10/fIL_-,,. __, —MOVED; jlddv&__.
RETORT X IN WHICH REMAINS WERE CREMATED: _POIQ�k
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 4E HOURS
FROM TIME OF ACCEPTED DELIVERY
NOTE: THE CREMATION LOG SHALL OE RETAINED IN THE pERM4NENT FILE OT THE CREMATORY.
4
aM51e¢
MATEOf r DpMmW NSWa
MATE Of
Division of =a.R Rees
Cemeteries m.�ampam
Te¢ : �,iYYari
Authorization for Cremation and Disposition
T Agorbdlw EgmmW EecwnL<ebtl and a18M pr IeY gareamm MnYrmlon.
I� Bhrlm NlaMfef: 7[3
Cy m.1,Namc PM1!VAALLmeavy
aemv�: Z, na E.t n,P ew(+'pM AAI 17601 Rnae f'K n'h10
CREMATION IS AN IRREVE M& AND RNALPROCEW.'—
Cremation IN demur me try placing me mmein s of Me remained aM Me wnbimr tdelrq me myna irm a aanmbn camber wnam
weyartmWyattt tapir' a MA aM Acme. i,leM1mfaM Ilame WIIIMIIeraN aM wnsume ereryMhgez¢p[Mne anEnMa1,
wdlid m all Met wille comAft onry eamation
creafter Mosmarn,measmlP'y nrm IaBBpnedeeMnm ID RRiW¢all of Na remains and dinner meter&nd th oamatlon
Medeman N Some mat and Weed,
Mewed are be IeRmsed TMrnmcM1ryAw. 11mrM Mtlto! remains
e ane(weMe mafaeyfia'n
Me mined ane me immune
al and fvtian malaielvil be aiyla6N IXy�gWrcE by Iev. The gemmall rem pal w[a mxlanlo
pulverized AGl , inbsmallpa¢5an0OIas f ides eewes. Da�rlerVMM1 LTYYEMWnpanMltyen Wleahrotl unN no
alnBlefieameMhracoNnlzableac cbbfel lYeue
OPENING OF THE CONTAINER
TFec =m mry mly open the contend,ndalng Memwen¢91 human muni N handful circumstances soon Y ro OMNm Ina
Wrom delivered
Mather whe IaMedur durable
remm reemDloyas care molar or
romed tDrypmpne rc
M1Men Tnoivert NlhenE in a conhinerw4ich rs nd eubabla far[urination aucM1 ea cenmanletarreMal mke5 me
cM�tlory Mllrquhe Mamemmalrm pa moreelr�OawldMewntaMl bfMXeccepb me remalnP. ills opMitq Ma
¢cIMMPlor V,eaW6�a'ormmWyarMNala TMovNUYd[efaeewMa¢eMVAAbrbre in pinmW.null NgN[y vgrMpaY
IDIMIRGTIdI pF ply=-F'Agm / }' /�
Nang NpemeBK L.A QUA r✓I r4�Ylile�nuse. MmtleISMAs. 4/lVUYtC([_
Iap 14mM AdLpacQ STQue Aral Ql —Choy L. ,i Y2IV
pe®INOamsIr 0SRr9 (OFIS- fl 4tNOw AtNA k) rJL4 o
Saw, ON P(r Api DDM0g-al-jKW wNDONard lR— a(— AlVFo laAnMeIYMaR -
Oesu¢tlm o tmb/anbYw M~ml W Im w w eRmn/e�6
[ l '?a-e T i dn� T ' D KEN 1.iue.c�.
PERSON IN=DNIROL OF DRIP6RION
fRvsm(9f inocromIcrompai owoxEauromepnAlm
o{{q aipa Rqk
Hagen ADDY
R-
ic ✓ INJe have no knci men Me d1cr a exenmtl a Yemen instrument pursuant to radio HMlm Law BMW 4201 or
wnmen9 elreNora MY the DlMOSN main (s,on of his or remains ane Ans are me Gerdan Mond Many uncer eased Header LAW
m5eclian a)Ot aM M1eve me ngMm aumorize cremation oltne runeimotme eexamL MipurnktlorMlpbaMGwwp is u
raiders
eft;at=. m .� �h,Telees�
DOS-IeePe IRe. obnsl rase 1 as
Aufhodramon for Crematlon and Disposition
omramn Nearew.�
1. APao��YeotlbwiB Waneb PVbNeaN lsawfi 4%pk
h Team��ie�' ryper
0. Aan4%q.Nge�r®etlgpvWr
7. kqo n �tlw.vaere®.ebmbaearr.ievie:�eneoatb id+iv.Wmwa.v r,
0. Ae1YolaN viaYlue'Mm Ma NVYOtvan Ymatpnatb PW4HmBM1lw9e6ma0H(]},
16 AtlYPvl olNerefemvgve Paanaltltlambr.IpaaeMPeYtOblll,Wa.'eR rAmLe NC
toe. N,¢tllw�ea�aln 4a3q MENUYtlh6®iEatlMOMa®MYain Ymmi P.aatlm PWCNeYb
ia..smw,azo,m.
au THREE MNe4Yhospf
JL LMb tweoi aa�m NtlWhalrtloe Eeueeetl NeemlmYll�oeauy.�YP4 w.vu�4,vuwmw4ndant
vrabtlleBUe+hz ertl Nat BnYswli neNlllLS,.ae�maiE ppmOeYCE»[INk ANXbbConfpm. Fallwbnmeve
a�bo pnw m.,.mason mar mm m wb m ve em-r{.'a osvmrryw- wnei.
)(- llw wb ai5im tlau��mxtlaolwdnti�b L,ID�aI � �Q.��-V
igm9n9Ne removd orerry oaveiPmvVaaraiotlW aleAae oavne9Ne halnxvayrnTy mamEerNNe
a�er.;enea�o cmxrve. �"ti'�
am�aownm m,mn mmomim �mnm
waaairnaeen Ne�,wwarmnee�awm anemmuea rw.on.i n.m. icnb N.
mimmerc.wnn me remar,a wn n.ereayeegavmmxm nn�.w�norenmm.wa wr cmmwon
�IMJe M1areby euberk nnNwapslYwy
ro c remain b.rema��or Ne eecaam
Th8 Pe sraatrox
me rsen aw,mtrmmmm,reene nanemd,.nr.tle.a.o:.anamaeaan+mr:
Name:mr sNxewnw Eeaem � xmrFl.atl Hine
�N� mte us m.ocosmsep,¢ycm�W.,N1'198)0 �stss�-im
n�.�r.e,enr.tlaeo�e asaeroe�aevbb,c.
�eY hU e6 7o i�YNAJ �nTC �iO
rtr.a�n�.o..ai�saememrleemw.�aa.a�aeel�rs -
P`aw.omr
�aa�ebswpurrmtl
tlemwlab PbyCLlab'FustlllHa by I
I�rrr
b paWlaly�Ytl�sl //
Authorization for Cr atlon and Umpmtlion
ammoevy
'X' vtiww w.m.aurtlnb�.ue bs„aaem,ee,dym tma.y.mom.lai.
cxu�n.9o.n.o-,y
+ten mm'arom ame�nm
an InMMtlemflnM, e�®py WMYq
CR
ONEMmeldb w
�Munmp9l Lfta=M R IpMO�lldvl l9Mlnlm6 tmnpatlup]fmm FbYtlllGa'FnYd llme
.�ebeeoueeompp,9 NAM Oln.-Y P/a3T�
IMMiMYYtle4Zban:meaYmhYEManErecwndetl�wnelmen eeeroorel egb OpyBFarmey MOgpC W de..
n6n p � 0 ttl `/ pm�ixse Om�'�
•mum•wn�adisa�sr. yy-- /
mamwlmtlmtamw by LTC A y (� 211 `/ wmoraan
U.wtlLM9py rurdwn. t�®r
tmausat4rom.spe sd.emuwbr tarn `�"""
rti .n.r
avlb4pYEWbf9a•19 Ynuw4rab Xs ermtim
rM'•tlM�I a�mpy N tlY6 Au(Fmvatlon Fdm,
rR9F�I9)ma•tl pVe�M1'•r•UMF 90n1911n wntra atlb�eltlon,wlq py dpmn9�b AUNOrImtlw FOnn.attxt(c)
m tlb•mvmY mM mnpYMw9e OI Mu bT4en—n9tlm embiM'vn IM1's A W tluvtlm Fmm entl euUtorimlzl tlu lOregOLg.
dpMGYW�tl9ra QV�'V a / .a110�-y / I
ZI& slo -6 Tz ' 76 g
AMe�)�, v5r
DJ&18pBtIRm'.avia F9t9a9