Allen, Dale Morgan Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NV 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: f�/NC,US
-- RETURN TIME _�_jfrrp
DATE BTIME REMAINS ARRIVED AT LRfMgTOgY �:
NAME OF FUNERAL DIRECTOR OR 0.EGRISTERED RESIDENT DELIVERING mMAINS:
I 1 S ._..____...._ .
NAME
GAS E ➢ /✓E^
TYPE OF CONTAINER
PLACE OF DEATH:
ESTIMATED WEIGHT OF REMAINS S CONTAINER- 11Eot6
PLACED IN HOLD: -
-
PLACED IN REFRIGERATION:
DATE OF CREMATION: —'-
____
TIME STARTED! - _TIME COMPLETED: _
PLACED IN RETORT: _074_'d AL n
RETORT N IN WHICH REMAINS WERE CREMATED:
DETAILED REASON FOR DELAY IF REMAINS WERE CRTED MORE TNAN 4D HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SHALL PC RETAINED IN THE PERMANENT RLE OF THE CREMATORY,
962
///��� °epartarmit Of 35tat
SEW MY Division of DIVISION OF CEMETERIES
°FP°°"'"'" Cemeteries sicker
fly
e14652O
Authorization for Cremation and Disposition
AThis Aubarleaaon Form must ber oomplamd and signed pror to delivery are/m(ains for cremellon.
Data H ILC Z n�Number,
T Pine View Cramalonum
Crematory Neme:
Address; Quaker Roatl Queentroury. NY 12800 Prom: (518))45o147]
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation 16 commake our they aressubiadeao intense hem dfinno The heat and Romenwllll IMIMn Knd mantal aeo�remsns�la adm1f meaner 1.
c me nuan g e.uptboneaMmetal.
which are an that well be left afar emanation.
Follewing cremation, the memeterywill lake remarkable eons se remove all arms remains and WM1er mMenal from me mmation
Uember but come minimal dust and re allows likely he left behind The crematory well separate incitleoal and foreign rnaledel tram
the remains and lM1alMidennal and foreign means all he disposed of asrreguired by law.The cremated remeire all be mecharmal
pulverized Into smell pieces and placedinn a designated container or W .Cmrral mnaine gemnlly Me "I duntil no
single fragment in recognizable as skeletal Ni
OPENING OF THE CONTAINER
Te crematory m"Only mean the"foiner holding the untie d human remains in limited daUmsWno .such as to conflml the
iden4ty of me becommid w W ensure that no materiel is endow which might ioryre employees or remake Me uamebry pmperty.N
human munmers am dellvaad Ina seasoner which is not suitable far commission Buch as ceremonial or rental cnbl,the
rema gcoil require MM Nan aim the mover Into a suitabW conslrar before D aoceps Me mains.The opening of
wnbinn or He transferor removal of remains well ber conducted before a ulNem and will be done In Portal wM dignity Men reapMl.
IDENTIFICATION OF DECEASED
NameofOe SmMkV Dale Mogan Allen Medsl$latus: Maher
Last Known Atldrms: 90 Perkins Drive Fort Edward NY 12828
Plemof0eath: SO Persons Drive, 90 Perkins Dave, Fort Edward NY
Sex El MQF Age'. 54 DOB: 07OW1966 Date of Death: I'J ° EBumMed Weiga�
oexrphom of cdwWcx nakrzr in which remains well be delivered.
PERSON IN CONTROL OF OISPOel
(Pa fe)in Sol of Nspoaifidn.Witiel ONE of film bllovmpl
l am/We are 1M designed agent of me marketed designated in a will or wean indmmeent aRCMW purfil W P able
Heats Law Section 4201.
///O���R///'''aaa
" ^/ INJa have m knowletlga Mel the deceased aseouled aviian Instrument purwent to PUMio Healih Law$edim 0201 are
v Iamin9 direc4om(orladiepc&IIW Mhisorheo==sar7 are the Fersm(sl having pmoMy undercuts:Hei law
I on
on 0201 and have the right to aNhome cremation Of" remains M the amend.MylDur relationship to Ma died as of AS IA
lima
Dale Morgan Allen
r"mmmo-+awl
DOS-1888-f(Rev.OWLS) PageI a
Authorization for Cremation and Disposition
((rust rvom the gal nerowl (
Number,pt—Deemden'.
1. Aperson designated in wrilinO Wrsuanl to Public Heats IAW Sedan 4201(3)i
2. The surviving Spoum',
3a. The sadvinO comeed Wnner',
3. My surviving drulb eigMun years of age Or oil
4. A surviving derenli
S. A ill rig Ads ng actual rare of age or doer)
S. A lawlully appointed guebien',
T. Any Roaon(s)eig hteen years of age on olderenlilled b share in the adds and very every ebsest in mletionship 10 Me deMa ..
0. A d my appdnled finuriary of the all
S. Adead Mend ar mlalive Min has executed a wrlMn statement pursuant to Pubic N¢alP Lew SWIM 4201(7)
10. AOier fisral officer of a cou my d a public adminlagatm a pasunled pu9oant to Me Surrogate Court PmW ure Atli
10e. Any final peB who is ad ing on Cara if of the deceased and who has executed 9 when comment punuad to Puble Health
-aw Mail 4201(7).
����yyr-f4��n�� Neu(''l�Al�lTH,REE of the mental
V a lmmby did"that Me CWy M the demo does net cOMdin a battery, eatery pack, poser sell. mdiDSMv Implant.
Or dicadNe device and that any such mammas view removed Well eudWon ofthis AuM Hzedon Form_ Fallumtorl
these
bodies Monte CMMMUOn may rings In harm t0 the Manuel and cnmabry p onnel.
WIRue aMrm NahnBwations have been MAP to DONNEEENHS MICAS
ragading the removal of any persOMl property oregra Mlrg dmluewhdh any peal signing badevor any M1ndly memberil
d sadMereslepmsome. Pine Vlew Cremadmum
he net responsibl¢for Me removal of peanel gems More the container or boom the rem1M of the dMaq PMOMI Items left to Na
[connttaiinner Or with the remains wall be dedreyad 4Me cremation process and cannot teaW Ileved lightcm on.
�`'/
Ime Mreby authodi Pine Vi Cwmabrium
toccremau Me remtlrm Of Me deceased, w�
FINAL DISPOOIMN
TO reroNe Ion gem ied remains of the demised from Me demclory I8
Name' �✓' IT
Morass 61 MaiviPnaM, 5�A - )4 �- �V2M1/3
The aamated remains of deceased vial °�elaPoaed vas fullare:
Qiden 4-�NT—
I )
II he any math the prison named above does ml lake posseubh of the cremated mmai00,
Pine View Cremebrium eaMMNedb ONepmaemvlW
thewmainab C rr.,�uFFfilIl oY ddNmry
In p¢wdn or of regideme mail.
Dale Mdgen Allen
trim.wo-mmh Page 2of0
D05-1 WISH(Rev 08115)
Authorization for Cremation and Disposition
///���(rad✓rtm klrowing)
UWe understand that remama are not claimed within 120 days ofcremetloo,
Pine Ylew Crematorium may dispose of Me remains in
an mainframe manner, such as by scattering.
CREMATION CONTAMERNRN
�—
An um to be used as a mntainer far the cremated remains nu been pumla sed from
and is deacnbea as fmlan:
Me understand Net Word um is too small to had Me entire cremated remains,an additional rigid container may bit used for astray
-OR-
An um he not yet purchased. bWe understand that tlno um is puMmM or OMerMae fronded
Pine Vewcrematonum art plain Me cremated remains in
N
a rigle Wmpomywm✓ner for earwery.
This AuMo mtl Form was pmWded by DONEENS MINAS was erewhN at
CarkWO Funeral Home, Inc
08 Main St. P. O. Box BT Hudwn Falls NY 12M9
and Is Signed by the Imerel Metal as whines W its Saud n.
Unim harm receives a complaint copy of MIS A vmaexai Form.
The pereantst ManWi" below seem the Ramada)N cm brol Of elspatltlan,who by signing MIS Aumotlsatlon Form,atlasgst
tome accuracy and complWness of W Information contaima In sets Aumotlaadw Form and euthanaep)the,foregoing.
Signed this 20 sly of Ami . M 20
�e�+gnn Alen
hmo.rm�ax.. Dow.
maharani
WIC ESN: /1h.
DONEEN S MINAS
J Zii;T
�a n
Dale Morgan Allen
1)OS180154`(Near 0i page 3 of 3