Vines, Kathryn Pine View Cemetery g Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (510) 745-4476
FUNERAL HOME: . _ 9B gYU.��Suk�nn
- -n^� • .-- -._.._.._. RETURN TIME:
DATE a TIME REMAINS ARRIVED AT CREMATOOT: . __ $
NAME OF FUNERAL DIRECTOR OR RECRISTCRCO RESIDENT DELIVERING REMAINS:
NAME: _-.__._ ✓wb:1 L.Ua__. II,.'KC _-_ �
PE OF CONTAINER:
YLr Y! ---CASE IF
TY
PLACE OF DEATH:
ESTIMATED WEIGHT OF REMAINS S CONTAINER MANE_
_.._..__._
PLACED IN HOLD:
PLACED IN REFRIGERATION; _
DATE OF CREMATION: _ -
0�T
TIME STARTED: YEAR COMPLETED: 3
PLACED IN RETORT: FuoryEq
.1LL__MOVED; ___ j_
RETORT p IN WHICH REMAINS WERE CREMATED: R
fl1KT
DETAILED REASON FOR DELAY IF REMAINS WERf CREMATED MORE THAN iS HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SHALL Be RETAINED IN THE PERMANENT ALE OF THE CREMATORY.
Bupenment W Weft
— ) NEW PORK plVlSlOfl Of DlvslonreF C�EMETMIIEs
jam— �SSTA OF O C W
OPPO0.TPM Cemeteries 99 WasM1„ybn Avenue
ri 2231A001
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Authorization for Cremation and Disposition
This AlM anm Form must be compM" end signed prlorte caliwrY or mama rorwMOO".
�Augunz32020 Number /g60
Commonly name.ware Yew Crematory
Arcane:Quaker New, Communist, NY 1280A PMne:51674641477
CREMATON 19 AN IRRE ERWBLE AND FINAL PROCESS.
Cancer,a comed Wt by placing the remains of Me detsa G eM Me conainer holding the remains into a cremation chamber Metre
May are answers 10'Yemen Test and flame. The hest and flame WN mWeMe and consume evaMM1lnS eeceW Cone end MMI,
which are all MN will Ce MB after commands.
Following cremation,the crematory will take reasonable areas to districts all M Me remains and other m nal horn Me sedation
chamber but some minimal dust and residue whl likely Ce led Canard. The chemistry will eepemR inti lormil and foreign material fmm
Me remains and the ante l and basics materiel will W disposed of as mguired by Hw. Tlie cremesed remandvAll be metllan'ically
advanced met small pieces and placed Into a designated container or do Cnmses remains pmenlly an pules d until m
single fragment is ncrpnivble as ekeleYl Nsaue.
OPENING OF THE CONTA NER
The crematory may only open the container holding the unaremaled human remain in limited diamtlaMea such es as confirm the
Identify of Me dereaead ore ensure that re mabnal 'is enclosed which might injure emplOyeN or Manage the crematory panel N
human remalm are dall"red In a container which is not suitable for pemMon auch as nmenlal or rents casket Me
rsmatory will require that the remains be movW into a suitable contalner before it ski the remains. The banking of
antai0ea or the transfer or removal of remains wail Cie consul bebn a wptess and will he Mane in poverty, With minty and reaped.
IDENTIFICATION OF DECEASED
Name of Oecaased:Kai Vlnad Marial Status:mMvwed
Last Known A➢dren M Mountain Dr. Gareevmn. NY 12WI
Plan of DnN:11 "marine Street,Glens Falls. NY 12MI
Mx: OM MF Age.103 Iwo:09/26/1916 Data of Coach 08,12112020 Estimated waghc 60
DeEnlption of caskeumltainer in which Anal will be demands
Minuet cremation caskedpine/cardboard
PERSON IN CONTROL OF DISPOSn
(Penm(al M seems? sPoatirn. Laical ONE o{tlro Mbwbq)
dMWe an the designated agent of Me deseesM comer cold a will or written instrument executed Panama t h Public
Hmllh Law Sev9m 4201,
-�0R /
12 L4 Nine have no knowledge Nat the demasell executed a women memmant pursuant to Puni Heats Law SeNpn 4nI of
will comening Someone M Me duposi min of h6 a her remains and two are Ne penWts)hevag pnomy,under some Heats Uke
Section 4201 and have the fight id suffers uema4on of she remains of the saturated MylOur MSBonshlp d the deneasd is as
follows.
Ka61ryn Vines
COSABWf(Rev. 04n0) Page 1 oft
Authorization for Cremation and Disposition
Number 3 OasUpUm. Mysurviving tliilE eighteen yeah ot ago aoccur
1. AMeant designation wrong pursuant to POElo HAW Lax 6ecMn I201G);
g. The aurvivirg spouse',
go. noSrawirg domeadc summer:
3. Any soNwirg child eighteen years of and ao r,
0. A surviring meant
S. A surviving aiding eighteen years of age or dder',
d. A lawfully appointed guardian;
). My random)eighteen years of age or older entMled as$hem in We estate and who Mans cbeeat In relalionship W the de W;
0, A dud"Im0inted fiduciary of Me Name,
0. A close fiieM or reletive and has eaected a WMlan statement pursuant W Public HeeM Law Sedim 4201(7);
10. AMief fi$cal oMrer of a sou his or a public sure monarch appointed pursuant W to Sunryate a Could Procedure Al
11ye. My Omer menammTC is acdrg on occur of the deceased and who has executed a winter statement pursuant W Public Heats
Lax section azol(7)_
(del ALL THREE of Ire NAowlngJ
k� MeherebyalfirmMatthebodymmadecreaseddoeshotcontainabatlery. zoespark, powercell, radlanwaJohment
or nibs m device and that any such materials were removed prior W the esevvtion of the Augmentation Form. Failure to nmow,
Mw Items prior M aamatlo ry n m result in hem to M m e craatwy, b and creemary penonml.
aC n Me ettum Mellrebuctions have bean given to amor Kmrokpa
regarding the removal of any personal pmpeM or other Ming olvelue which any person signing bdrvx or Any family member W Me
deceased wanes to pre$Ance Pine view crematory
ro.wm'm,.?
is not re$ponsibm roc tna remwm orpamonel xem.5om ma noma�nar orthem tin mmams W Me aaraame. Pomonal dame let in me
comalnerarmM Me remains win be dammed byte cremation process and cannot be retrieved bear cremation.
—V VYIe hereby aWhaldxe Pine View Crernelory
wmm.aymM+f M mNmato the remain or Me decoased.
fialiel OPTIONAL)
bale hereby authorize Me named funeral director to provin for dmiwry to and cremation by an anorak
conernamory, If dammed necessary In Me opinion of the funeral Mractor, And to amen MIs foam to provide Me corrM name and
Address of such alnmam customary.
FINAL DISPOSITION
The person authorized W remim Me cremated remain 0 Ma decemad them Me cmm e;
Name: M.S. Kilmer Funeral Home, 136 Main Sn Ge Glens Falb, NY CR803
Address'. 136 Win SL Go. Glens Falls, NY 13003 per: 518-74"116
The tremand remaimof dao9ased wit be disposed of as formes:
eurlm at union can.
If for any reason the parson mined aeon,does not mire nonesuch of Me cremation remmns,
Pine Yax Crerralory is authorized W give possession of
ryamrtq tend
Me Rmaim b M 9. Kumar Funeral Home pydp4yery
in pemem or by rxamend mail, r Kathryn Vines
DG 180-f Mai 0tGM Ps+. Page Rof3
Authorization for Cremation and Disposition
(huMMe nomm'ng)
Me undercard Ilan if the mm M are and cblme0 warin 120 days of cremation
plm Yex CRmabry
maymeposaatlrere min
an "Inevab an a mner, such as by scenenng.
w-. r
CREMATION CONTA NERAIRN
(tea 15 of Me farrowing)
An um to a used as a conammar for Me cram eed remains phis been purchased from
anaisdeschoedasmmwn:
IMIe understand MM 0 Me um Is an small to had Me snorers mn memoirs,an addMonal aid oanlalner may be used Mr devery.
OJJl1 '
x An um is M yel pu"aa , Me understand Met if no can is phadmill or Otherwise scoded
piney Crematory all place to cremated remains in
nm+.n 'wmw
a hod Mel summary coner for dNivery.
This AUMOrha Forma padded by Could Korokpa was executed at
MB. Kilmer Funwal Home
w~xo,.wn"
136 Main St. So. Glans Falls03, NY 1R8
am is sgmed by Me furerel reactor as wiMese bits execution.
Wle have receive] a compleler copy of MIS AuMWfDnon Form.
The amounts) idenlifled Eebw blare We persom(e)In control Of dlepO n,who by 6lgaing this AMfamos On Form.eRWI(f)
to Was accuracy and complebbY Of the Information wMalned In MIS AuM HMWn Form and authotlmfs)the foregoing.
Elgrad MIS 33M Mora August Rgp
RObad Vines
97 Governer Gr.Gleni NY 12302
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WITNESS: /
arim Kormem CQ tK„-_�//ry
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KOVryn VMes
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WS189&f(Rn. GWD) Pepe 3of3