Alber,Susan K. Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12884
(518) 745-4477 or (518) 745.4476
FUNERAL NONNO _--qp
++,, -- - - _. RETURN TIME
DATE A TIME REMAINS ARRIVED AT CREMATORY: WIuIID
NAME OF FUNERAL DIRECTOR OR REGpR�IS/TTERRIEO RESIDENT 006LIVERING REMAINS;
NAME _ _. S- CASE 0
TYPE OF CONTAINER:
PLACE OF DEATH: .--._—
C �L/41
ESTIM
PLACED IN HOLD:
WRIGHT OF REMAINS 6 CONTAINER_____.
PLACED IN NOLO:
PLACEDIN REFRIGERATION:
- .. - - - 1;vrAM --
DATE OF CREMATION: __
TIME STARTED; —__ _ (. (I L' I�TIME COMPLETED;
PLACED IN RETORT:
_MOVED:
RETORT 0IN WHICH REMAINS WERE CREMATED: - ---69%
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN VE HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SHALL BE RETAINED IN THE PERMANENT F li E o THE HE CREMATORY,
it thog2ation for Cremation and Disposition
or,cm...Fluor, e�mpwnw,
als1ei wus
TMs AtMONAdon Form must be completed and sfgndpnor to delereg,of remains� rcremadon.
te:Da E�Te�ip Number (O
QemaloN Name: Pule uxNV Grernelory
Address. Quaker Road Queensbury, New Yo* 12804 Pllnrm: 5181745rl
CREMATION IS AN IRRIMRSIBLE AND FINAL PROCESS.
Cremation is carried out by placing one remains of the deceased and the container holding the remains into a
cremation chamberwhom They are subjected to intense heat and flame.The heat and Some Fall lydu e add someone
everything samint bane and metal,wMM are all that will he left after raematim.
Fa[lowing v n, the crematory will take reasonable efforts[ n of the re our dns and other material from the
crinnothom chamber, but some md arms I it rut and resedue wd11 nkeFy be left behind The members wlII separate mtldemaI and
foreign material from the remains and the incidental and foreign material will be disposed of as required by law.The
ansmated! remains will be mechanically pulverized into small preces and placed into a designated container or um.GremNtl
remains gereralhy are puhttized will no slime fragment N recognichle as stNetal a m.
OPENING OF CONTAINER
The crematory may only open the container holding the uncmmattd human remains In limited dreumzbnces,such as to
confirm the dent"of the deceased or m ensure that no material is enclosed which might injure employees or damage
crematory property. If human remain are deivered in a container which Is not suitable for downward such as a cemroonial or
r laskeq the crematory will require Nat The remains W moved Into a subble container before N accepts the remains. The
opening of a container or Ire transfer or removal of remains will be conducted before a whness and will be done in privacy,
with dignity and respect.
IDENTIFICATION OF DEClEE\�ABEO ,1 /�
Name of Deceased: J K kg Mar lGlaNa: AM
Last Nnoavn Address: is Rransifigji,dr fiwor G2 ol iU4 /ZP'dY
Place of DBRUr
Se, OM OltAge:J— DOB: 130Z, Dale or OeeM: AIL/ yp Eafirtuatetl Weignt1�
XxOption of tasket/container in which remains will be delivered
CrImagated CardboardBo with Plywood s rmne Madel al38808
oERSON IN CONTROL OF 01SPOSITION
Person(s)in control of disposhion,ful l ONE df the following)
I am/We are The designated agent of the deceased designated in a will orsudden importers executed purwant to Public
North ldw settled 4201.
-0R-
DA I/WeharenoknowkdgethatthedeLe d"s dawfiftenino-umempumuenOto Publk Neanh wsdion42810r
will containing directions forthe disposition of his or her remains and(Oan4inued next page) n+
WH6uryn.o./zN xes ghumN PW103
I am/we are the cerson(s)loading priority under Public Health law section 4201 and haeethe right waNhaue diameter
ofthe remains ofthe deceased. My/our MatlomMP to the aewarM Is xfgbws:
IlmMfiwn[Irlut MbwJ �' �/
Number�Descnpticn: ksyit"
pursuentM Public Health Law aseel 4201 (3).
2 Thesurviwnaepo
2a.The surviving demanded parei
3. Anysurvivilg Mildeightcenyeamdf oroMe
A. AsurvMng parem
S. A summing stbling eghteen years of age or alder;
S. A usefully appointed guardian,
T. Airy person(a)eighteen years of age or older entitled to share in Me estate and Me ware closest in
relaylonship to Me deceased;
0. A duly appointed fiduciary ofthe estate)
g. Acicee MC ormiab"e ohmexx ax nsfafdnentpumuantMPudic HeaMh §0201M;
10. A chieffittal officer of a county o a public adminiahator appointed Wrsuant M Me Sumgate'S Court
Procedure Ac[
1l .Any ether person who as acting on behatt of the tleaaeetl and who has executed a emitted sbfement bedstead
to Public Health taw§1201(7).
(fplfjgl/llL 1HflEF aj rMfalkwMBJ
DA I/We herelry arum thatthe body ofthe deceased does me certain a batten,batten pacl4 power tell, ratlloMFre
implant,of radloaceve davlce and that any such materials were removed alor to the exertion of the Authorization Form.
Failure to remove thee!Mine Poor to vemeMe may meek In harm to the crematory and crematory Personnel.
1� A /we herebyaffirm that Instructions have been given to awnmd.mr.omd [assbNr6eMY14100 regaNingthe
removal deny personal property or otherMmgof value whim any person square believer austerely memberofthe d«eaud
wbbu to Preserve. Ioemwwyndmrl Pine yiewcrematnm isnot respmnsible for removal of personal
hems from Me container or from the remains of the deceased. Personal Hemel left in the container or wide the decades will be
owe rayed by the cremation Provo and cannot of rebleved after oenauon
3) A /We hereby authMae wouwrcmd PI Vkw Cre roaemae the mmalne or
Me deaaatl.
F NALIMPO NION
The Pereen authorized to racesrver the Inemaletl remands of Me deceased Man Me crematory ac
Nam Berm Furemad Hem Personnel
Abdress 11 I-ahweethe S Quessinstpurv, Nbir Yorl 128M Plsons: (5181761,003
The cremated remains of deceased will pe disposed of ae follows:
Realm to Mmly m the boosted
If for any reason Me person named shove does not take possession of Me cremated remains,
Imiremywdl P' Y C na auXwrtzed W give possession of Me remains to
Iryrmnm.,em.rt) BkerF ne21H by deliver In Wood or W registered mall.
oasesau new rreol •—+� ^—,"
LUQHItM/WbwNpl
7�q IMk ulndersMnd Mal d Me remains wxpltlaYreO wahln 120 days ofcremation,
(""Wi vlwf Pine Vew Cremabry may dispose of Me remains in an irredrevade manner,
such as by scattering
CREMATION CONTAINERNRN
(IpQbGONE oj(Mjo110 WnpJ
___AI um b de users as a container Mr Vie cemated relrlalns has been purchisse l from Baker
Funeral Home and is de¢ribed as follows'.
IMb understand Mat if Me um a ft small to hi Me entire cremated remains, an addlVpnal rigid contester may be used
fordellvery_
-OR-
_'ILA__An um has not yet been purchased. UNa urtentaM Met d m um is purchased or otherwise provided tow*mwv
....1 Piney Cremabry will place Me cremated remains in a Nis temporary
container for delivery.
This Authorization Form was provided bypmwakiwmmel Me
was eaecu ed M ywewammwmel
rdiv aeeseml to 5 t] bu New YOM 128W and is signed by and funeral director
as witness to its execution.
INJe have re erved a complsled copy of Bra AuMorizatbn Form.
The persa re) s entihed Dhow Were Me parsons) M mnbd ofEisposition, who by$Wing Mis Authorization
Form, 8"(s) to Me accuracy and camplefenesa MMe M(omtafbn confaMesf 0 Mis Augorkrabon Form arld
aulhorae(s) Me laegoiig.
^this di S bi 20-ap—.
✓ d uuV
12,
v spmrt
n sywe
IMTNESS:
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a..wp.wa-.w,�e�manaw� n..soa.mrw.n..
Foresee H R dBIUQ
anww��xNmr.