Mason, Ronald J. Pine VRcw Cemetery $ Crematorium
Quaker Road
Queensbury, NY 12804
(516) 745-4477 or (510) 745-4476
FUNERAL HOMF: _.,___
_ _.,.QQrISNO
" - - -. .,... _ RETURN TIME
DATE & TIME REMAINS ARRIVED AT CREMATORY,
NAME OF FVNFRAI
_ 0IR E C FOR OR REO RIS TIE RED RESIDENT DELIVERING REMglryy; '1• I
NAME:
__...._.CASE tl _
TYPE OF CONN TAINER p1',,` _ e ^ /O^
_. . / �RIP✓t '. . . IP'E/T UW✓_ try rE �
PLACE OF OEATM IIO CMnt
08TIMATED WEIGHT OF REMAINS & CONTAINERS II
PLACED IN HOLD: -2� 1Ff
PLACEO IN REFRIGERATION; -
___
OgTC OF CREMATION-
TIME STARTED;
9 tK at1 _TIME COMPLETED,
PLACED IN 9 RETORT /, Pf.'JC AN . _MOVED
RETORT II IN WHICH REMAINS WERE FCNEEMATCD: � IL4c(f
DETAILED REASON FOR DELAY IF REMAINS Wl"E CIE i -MATED MORE THAN AO HOURS
FROM TIME OF ACCEPTED OfiLI V E0.Y:
NOTE, m9il L4 nLl oFn -
• 1n[ PNI l[ UE nIE [nemnTORv.
New
York New
a
)IvisIDl Of prvl s
oneCorary,oul
Cemeteries AwrinUir
ne�Sn a � vwa
.w.wcon4ok
Authorization for Cremation and Disposition
This AUW dN w Form must be cOMPI tl and signed prior to call of rentals for cremallen.
. Metal Number.
Crenekry Name: PlMvieacmmN dun
Address.21 OWker Rican Ouealedlry.NY ii Phi.. (SIM 7454477
CREMATION IS AN IRREVERSIBLE AND all PROCESS, 9 Am_ __
Crema slbcedo out by plaaw Me�ems of the to whore neat and farm Tom MNd and Name Addt IMra1 WAminar n MUM everyBNng 0Wrr bo sin MnNYI
aroma M
xTlcdare all mot will09 laid a after Cremation.
oriental cremation meaamatory WIItake reasonade leftWremoveallsinesremlland lm de«lal upon ndfmanmm
Memnecs and th minimalduN and
egin mwnalset LIeXclOhand TMultry Mae Theraleil4iderMland lwllgma nh«
MemiIand MeI mmrsAlaM locale"mNerial MAIIM a N lw Oran Cmred nv law. Tne gemalea rem h w.11Md uMl My n
Wlveimd into smell pexa end eased Imp imsielvlM«oleircr«un. cnlMbd remMrs generally am pulv.dretl urtll m
.MNN fyagmxR M roropnmbla w.Iwlanl tmM.
Difiggrafth;OF THE CONTAINE4
peace naN
The crematory may My or the peace me a unoemaW ro human mans M dmilM urcumslaMea wtll as to mMlrm M„
edenn of Me a¢reaaed or bmwre cow n0 matene'n er lmetl wMtll mipm Inlwe employees«damage Tar oamalprY popes
human assume are delivered In a container which Is not suldGM for aromatic"such as ceremonial or rented casket.Am
matary wXlr uim Met Me remains be M"a Into a vu lM1tlle container Mlwe It accepts Me contains. TM Weneng ale
mMal ner or Me transfer a remrval of remaim HII M compared uskre a wareee said All as done in Treaty,, si agnXy and respect.
nCM FCPTON OF DECEASED
Name Of "a"eld J Mmm Mantel SdMe
1aq KrWMm Addreas 1 to CWey RL t0. ConarM. NY Ti
PbA of Dmth 11a CwMy RL 10 c« NY 1=
yolk: SM OF Age: 74 DCB. oiwli N M dDeane: EadmIaJ V1a4M age
Dyropnon o1m awn finer In vat remaiN VIA de d wsrw
RypplmelerieY"MaYmanufxWra) Malmewa Aura W>tl eM CatlloardCmmetlm CaNYror
OF DISPOSITION
(Porym(s)In CMbdWdrsMYh"n. army, VVE amM1%'wnnp)
I scones year Me WwgrW agent Or deoaa9 MYgrg In a tell a Wren ireMmmnt lNCulep crucial to Public
IMNM Law sectia 4zol.
FOR-
Afol— pWe have no WO cage Mat rear demaXC executed a W In. merd Wall of public Roger Law Nor 4201 ors
M 11 Weaken cloatime W To dlacoaulan or his or her remains and Iowa are they,pe'mn( l cal prloMy under Public HmXn Ise
etll Son 4M1 and have And fight W aNhorue cremation of Me remM m a Me dA'eemd. snappy andllonanlp b They We WIs as
follcwa. Ronald MmOn
DOSMmnf(Rev. W15) Pepe 1 d3
Authoriution for Cremation and Disposition
�( (�"w Me mawast
�qy, IMw understand and if Ne Rmtins are mo GaimeJwtltin 1ACaya MOemmi d.
Pimmm Crematorium mry tlrsWU UNe remain In
animMmade mamv, wtlt as W acathemq. ucAmnn
CREWTpI COMAINERNRN
' llpm@t/O�NE MP arn fM'owmy
yl�� tinu to on uM contend fw in Me aama in Hs noted
kO remain pinheaded hen DeAamore d Funeral Nan . IM
C'a and is desmi as Moves 61, � -Af1
IWe understand Too If N¢Um is and small b head the NNR nomeNd RmBA an N54pW rlptl l mr mry IN mad fin NVBry
OR-
MUmar wWrtlla9ad. IMb UMerslaM tlAltlM VnieWrNBM]V aNMam povNN
mi MCremetoam w,ll plain the aemond demands in
a and lempararY mMainer for delmosm
This AutliONatlm Farm was providW b/ RGfertf Cvlmlwe �a�xn4 was imewkd at
Densmore Funeral None, Inc
T Sherman Avenue, Co icon, NY I= Maw xvexenl
and is signed by Me funeral disci as wadi to Its,MICAM. �w
II have reeciven a completed copy of this Auap nForm.
The persone)IderMbd nalwv Wan NN pareantst In wmand of d4pmltlon.Mro W slpning Nis Aurhortradon Form, lesions)
No Me aeWrery and cornpbMMB Onb IrNwmetlon cbMYned In t/�Mes AU�MpM Form and aulhorlaem)tin foreeoing.
Signed then 2Mnger 6�of 9epNlMRr •m 20
End Sa MO✓
110 courar Rt 1g, Onama NY tram
w �
RU¢e11. Ca1Y11M
pa/ouafrrWnrnmuaW �,
i Wip
RMak AVYon
WS-1898-fosev.WIN) Page 3 of