Sheridan, Claude E. Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12604
(516) 745-447-1 or (518) 745-4476
FUNERAL HOME
_.._. __. RETURN TIME
DATE & TIME REMgIN5 ARRI VEU AT CREMATORY: ,L��
NAME OF FUNERAL GRNSCTOR OR NFyRIS•TEnea RESIDENT UELIVaNNO REMAINS:
I
NAME -. _ _CFI k SWCRrOflN y u _.
_. CR5E 11 N�J TYPE OF CONTAINER: t 1'1 I /It 11 / p0'
ttyy O(F_ j1 L MW _kVA: ✓T`iwClWtLk'/ IR PLACE OF UEHTH. .S Ej TIUREn. �O AP) V"_- L - YIM
ESTIMATED WEIGH OF REMAINS M CONTAINER -- 1LK)y
PLACED IN HOLD:
PLACED IN AeFRI"RAnOn
/7Ab
DATE or CREMATIONTIME
PLACED IN RETORT:
tGb�n TIME COMPLETER.
/-
PLACED IN RETORT -Lf 6oh
1 MOVED �,
flFTORT II IN WHICH REMAINS WERE CREMgTED:
DETAILED REASON FOR DELAY IF REMAINS WERE CRCMATED MORE THAN Ar
FROM TIME OF ACCEPTED OELIV ERY'. THAN q0 HOURS
NOTE: THE CREMATIONLOG STATE RER -
co xlgE vk'II U( THE niORY.
Autu mom.m..maww
horization for Cremation and Disposition
pm�ammm Coco. wm��,:.m.a
den 474,R25
exam Can Irmo
Mai
This AMpMeaon From muathe eon" Ww SiOWpk As deliv aremains Ior eaemagon.
Data: 91181A Number io4y
Crematory Name: Fine Yew Cremaory
Address: Quaker Road. Queenabury, New York 12804 Phone 5181745Mn
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation is carried out by placing the remains of the deceased and the Container holding the remains into a
cremation Chamber wheretheyere subjectedto intense heat and flame.The M1ert ark Ramewltl ll101ente and wosune
gveWhineme baneaM mehl,wMdr xa allMrtwill he kR aRerfrematlon.
Fallowing cremation, the crematory will take reasonable efforts to remove an of the remains and other material from the
cremation chamber, but some minimal dust and residue will likety be an behind.The crematory will supreme Incidental and
foreign material from the remains and the incidental and foreign material will be disposed of as required by law.The
cremated remains will Ise mechanically pulverized into small pleves and placed into a designated Container Or urn.Cremated
mains generally are pWvMzetl until no slate fragment Is recognlaaMe as skdHY tluue.
OPENING OF CONTAINER
The crematory may only open the Container holding the untiremamcl human remains in limited circumstances, such as to
confirm the identify of the deceased or to ensure that no material is encased which might injure employees Or damage
crematory property.If human remans;amdelNered In acontainer which is rot wNable for cremation such as a ceremonial or
rental resbq the cremdory will require that the remains be marred Into wkable container before itacceph We remains.The
Opening of a container or the transfer or removal of remains will be conducted before a witness and will be done in privacy,
with dignity and respect.
IDENTIFICATION OF DECEASED 11
Name of Deceased (t.101160 F �fLd Yi(`ln Manlal5tatus: /`vinrr'.rf
Lad Krawn Addresser J5 � 1 y. 2
PlaceE of Death: 353 '� f7 Zd ltacR� N 12?(q
Sex: *4 of Able �� 13013 � II � 1945 �teOo : 25202Z EehmdadveyM: 76
Description of raskabcontainer in which remains will be delivered:
ZgrrujivatedC dbg irl Box with Pivanood5 k Mod IR3880
PERSON IN CONTROL OF DISM51TION
(Pereon(s)in Control of disposition,initial ONE of the fallowing)
_I aryl We are the designated agent of the deceased designated In a will or written Instrument executed pursuant o Public
Health law section 4201.
-0R- p
(,,r/���J I/We have no krowledge that We deceased executed a written instrument pursuznt to Public Health Law section 4201 or
a wi11 containing directions for the disposition of his Or her remains and(Continued next page)
L qD n
wsysaM lwv.asnol w gmvwM Pali
I am/we seethe persons)Having prompt under Public Health Use section 4201 and have me right to paehodae orientation
of Me remains of the deceased.My/OurtYatlpn ipm the deceased Is as follows:
(InsertfmmtlK liSf Mbwf (n1
Numbm-a-0eecdp0on: 1 tP_
A e tandesi nalmi ward M Public He w alth la sadean 4201 (3)
Z 12esurvivitq Sp w
a.TM surviving domestic poster,
3. Any surviving child eighteen years of age or older,
4. Asurvivingperent
S. A surviving sibling eighteen years ofage or older;
S. A lawfully appointed guardian,
T. Any person(s) eighteen years of age or older entitled to share in Me estate and who ialare dp9ast in
relationship to the deceased;
B. A duly appointed fiduciary"a estate',
9. A dose friend or relative who has executed a w nstatement pareuantim Public Health Law§4201(T);
10. A chief fiscal officer of a county in a public administrator appointed pursuant to the Surrogate's Court
Procedure Ad;
1N.Any other hereon who rs acting on behalt of the deceased and Who has executed a wdben statement straight
M He NIL Health Law§4201 OI.
Frnrfier ALL THREE o/be Portents)
I/We hereby affirm Me the hotly of Me demised does not contain a batery, battery Wtk, power cell,radioactive
Implant, or radioactive device and that any such materials were removed prior to the execution of Mis Authorization Form.
Fa�ilu'rfe to remove these Items pia to handles may resua In have to the crematoryaM Chemistry persormll.
(� I/Wehereby affirm that instructions have been given to rtyrcaaa.ed�orrcl5 Baker IXM59 regarding the
removal of any personal property or other thing of value wh'¢M1 any person signing below or any family member of the deceased
wares to preserve. lvemmm gel Pine Vimtranatons s net responsible for removal of personal
items from Me consumer or from the remains of the deceased. PermrW items left in Me Contabrtr or wM the nmsey Wit be
dotroyed by the cremation prorep arm ranrot be reVlwe l after colleagues.
I/We hereby authorize 4neves, ^<I w cremate the remainsa
e d ce cod.
FINALO SPO$TON
The person authored M receive the cremated remains MMe deceased form the der atory is:
Name'. Baker Funeral HomP
Addreseas lit StreetQueensWN, NnYo* 12804 Phan: (518)7614303
The Cremated rental of deceased sell Da disposed W as hostage:
Realm to family M be tledtled
If for any reason Me person named shows does pet take possession of Me cremated remains,
control rrei P' v C s aa0lomed M give possession of Me purpose
q,,,.,wmmsewm.l Baker Fungal Home bYdelivery In person or by registered mail.
inn
rmaaN,,,i�.met 1 server arrived rai
• Irnmol Mejolbwirgl
Me understand Mat if Ole remains are M chalmad within 120 data of cremation.
lwwmrwyn.we) Pine Yew Crematory may dispose of Me remains in an inehmvwable manner,
such as by srattann9.
CREMATION CONTAINERNRN
fIblONFwFth'folbwinp)
Anurn b be used as a container for the aemated remains has been purchased "in Baker
Funeral Home and is described as fellows:
IWe understand but if the um is too Small b hold Me snore cramand remains, an additbnal Wei ccnlalner may be used
Wdelivery.
-OR
�.,,/ �
-(�y_nn um has not of been purchased We understand Nat K no um a purchased or otherwise pmvlded (wwwwy
...w) P'ne V Oremahry will puce the cramated remains in a rgd temporary
container for delivery.
This Amlwrlutian Form was provided by�a vmwl 5 Bake 1110159
was executed at ww evvv o Baker
wvww'nome.an.ut L S O ab N York 128Ba eM is ii9rrad by Ma funeral dlrector
as witness to its execution.
IWe have received a vnnpkted mpy of Mis Authorization Form.
Tire persons)ida oll below Were the pemorki in cones donspositron, wem by sdrsW this Autlronzation
F ,, attests) 0 the accuracy andmmpletegress&the inhumation contained in this Authaizabon Fore and
authonzafs) me hredebri
sldneemB Wet m O / 1
(arnl 3Anr agia a✓ _
353 �Q&LQCIAM
win xsw sawn.,
Now"'
WITNESSEtbuff Baker
rurcw amvu M1VN o'rtirvee nines
Funeral Home Red M01100
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