Donaldson, Albert Pine View Cemetery $ Crematorium
Quaker RoaA
Queensbury, NY 12004
(510) 745-44)] or (510) 745-4476
FUNERAL Rom E: - , �L1S52H��(
.. RETURN TIME
DATE a TIME REMAINS ARRIVED At C 'MAf URY d
NAME OF rUNERA � �( [ / d DIRECTOR OR NECNISTEfl[O RESIDENT OELIVERINO REMAINS,
NAME; AA04 7)mQ/A erF, _.._._._..
/, _ .._. �p(pZ
TYPF OF CONTAINER H l
CASEa
o eNee CAs�CP.I �A,II CV.I� N1 PLACE _/---
OF DEATH.
ESTIMATED WEIGHT OF REMAINS y CONTAINER
PLACED IN HOLD .__. ----
PLACED IN REFRIGERATION -- - �'—'
Date Or cREmgnoN
TIME STARTED; /Z 5Sy T ME C
es.__. e 2yp
PLACED IN aeroar. Fi �—
—. ..— _ !- .. . _MOVED. !Yh�
RETORT II1N wXICX REMAINS WERE C11EMgTEP. .DETAILED REASON FOR DELAY IF REMAINS W ER[ CREMATED MORE THAN qg HOURS
FROM TIME Or ACCEPTED DELIVERY
NOTE E"AT ION LOG SHALT nr Re TARED R I HE - - -
oemb ornrscene
NEWYORK �IVISIOfI Of DlNslox of x'Nz�Q`oom
SiATEOF m Pie
OPPORTUxIn. Cemeteries
1 r, cat I+mei
Authorization for Cremation and Disposition
The An(h OVOnFuror mustWcomplY and signed party delmq olrxnalna for enmaaon.
Date: °&RSR020 Nw c / n y 2
cremalOrrNure: Pen Nw,CmmaYry
Adereea: 210u Road, Commodore NY 12804 Phme: (E111 TaEMn
CRE"TION IS AN IRREVERSIBLE AND FINK.PROCEU.
Cremation is carved M Iry among Me remains or Me de Sa and Me conrffirer nONirq the remain: into a chemawon mambw wiwre
they are eommodnd to'mNme new and name. TM I tand Mansell mnnemh and consume everything cameme bons and msml,
whim ere all Nat will be Ind altar cremation.
Following aemadm,He cremaNry wuI take rea enable Words to remove all of Mir mmeina end What m stand I from Mee aremaMm
chamber. but emme minimal dust and residue vnu likely Oar left Delhi ad category val weareu:imademal and corei°n mw col M1wn
the remains and He Incgental and um ign mateml van be apOers Was rmuirM by Nw. TMcmma re a,nswllbem% nlnlly
drivelled iW0 emae pianea and pNmdinto a drvignMd normal urn CmmandmmaNegenemnrampulwdudUMim
amgl.ImemamN maognlmma a.Fateul gs.ua.
OPENING OF THE CONTAINER
Tire crtvnatory may only over the mMa nerhdding Me urvcremaar human remain In Ii rated cumtlances such ad tOmnRrm tee
hi or Me demaeed onto manta Mile no mwend lemdayad whir might inlum empbyee damage the crematory Nomrty. N
human remains am de i"i in a container which Is not suN M for emma"n smile as mnmonlal or oral ca ket.Me
commaddery will myulm that Me mmtlm be moved IMO a suXable container before x heinds Ne mmalms. The W ll of a
mnmhm or the harbor W removal of remain vall be conducted bwwe a xiMms and will the don In pnvary,with dignity And Reebok
IDENTIFICATION OF DECEASED
Name of me a Nbwh MBltlWn MMmI51aMs: Named
Law"i Mdmu'. 318Gun46ge ROM, GanHVOoar yNn 611
Place of Cash: 315Oum Sponge ROM, GanevnoM1 NY 12531
Sex'. Om OF Al. 81 Goa: 09/16/1939 Nwofm lnbvb¢ozD E Wmw glrc 165
Northern W PsWmmdrm D wbkh remains air be"iv
Florence Casket Company (Cardboard Box w/wooden Base)
PERWN IN Cd MOF DISPOSITION
IP.morla)M Lrema a atpoamm.�omP a me MXWvutaf
lmn areteedesrenammain MMedeuauddeugnatalma WllorwrMen InmumenteKa puwantm Pubnc
though Lax aecnon 4201.
oft
�SL INJa have no moral Met the dadmand es a mXen instrument panuaW toPublic Health Law smlmh 4201 or
well conainlrp became for tle disp nOf his u her remains and me art We pmelsl having panty under Public HS Ise
Becdon 4201 and have to rgmho ashoNa aemM olds remains or Me denab RyMurmntionahipWN demo Nas
mime
Albert Donaldson
DoS-iW f(Rev. 04,M) Page 1 of
Authorization for Cremation and Disposition
Trend Ran me WN w)
Number, 2 Onvippun: clog Omaumn(K5b)
1. A cereon designated in writing pursuant A%himR M Law Season R0113):
2 The wNMrg mould,
an. The funding domestic Palmer
> My surviving Nip elpMmn"am of pre on Wen
A Asurvmrq parent
S A vuninry Mand eighteen were of age or 0i
S. A4w appciMM 9uar01en:
L AM pars lb)equal years of W or older ants]m share in Me etlak and wM l&are dal In relaral to the dOma ..
a. A duly appalMch fiduciary of the estate)
6. Adead meM or reative who has Edwards a woman dab tpursuing b From Meats law Season 4201(7).
10. Atlief fiscal Will of a caumy or a pWlp atlmimaotlor appointed pursuant to tM SumgaR's Cwrl Proedure Ad
1W. Any allot parson wing,IS acting m Mall of has 0cIXa5M and who hasexmkd a wrNen statements Wrauant p Pal R M
Law Section 4001(7).
ImTial PLL THREE of ore IWwmpf
i hereby ahem that hie Mary of Me recall dam rM ransom a oaMry m0ery"a power W0. re0aactiv¢Mdant.
or radieacmadevese and that any nM mammas were removed pnwm Men execution dole AUNo/Y WFarm. fallumbarened"
theme Items prior to cmmatlon an"result In harm to Me crenrial and rnnnel personnel.
IMb mail mnlnaNKdens have Men given m Rolland O. Noaa
residualhie rtmcaal of any pe90nal yopeM or Mail thing of waste which any Room signing deloaa My family member of has
femga5]washes to preserve. Pn¢VIEw Crematory
scausel
e not raponvEbfor Me removal of personal Items from the wmairer or fmn tM remains of the deceased. Parwnal Items OR In hie
confined or vmM Me remama will he repeated by as cnmaNm prmua and cannot be retrieved after crvmatlon.
S`Wle Mseby alloM PImU Cmmamq
ro.m.mra to¢remab Na remains ofthe dacNNd.
(ImtialovnorvAW
IMs hereby auMorhe ore named hnaral dlrectorA pmvlda for delivery ta and Monsoon ey On AftMW
channel If dammed mail In Me opinion 0Me Nmnl dlnchor,and to amen and Ards to Masada Me comedy name and
adrmss of such i W man mandatory.
FINAL DISPOSITION
The person auaonred to receive to mma remain of Me dew Ran me MMM7IS
Name: Compassionate Funeol Care
Pbyenu: 403 Mmte Ave,Sar aSchool NY 12W Phone: 1MMAO6aBaa
The mma deal of denwaxed was be dispoasd of as Mluse:
Helium TO parody
If M any moon the harem named aW does rot HM pGa nil the aemal RmeW,
Prim New Cre ma a eWwr¢tl to pM pxwpn0
the remains to CarWmtiama FureN Care, rim midstream
in permn m My o]Iffiod mall
nim xvawa AM ftW 8 Wn
m0 iewfIRm. (Al seen Ppe2 03
tAuthorization for Cremation and Disposition
Col Mna aManWMM.IRMeianmra as pxdalmea wMlp lzgderemaemegpn,
aloe Naxcrem.iwy mayaiepoaemmemmalnln
an lrrelrevable manner, such as by scanning M1maammN
CREMATION CONTAINERIGRN
("many ONE of Me Assim M)
Pn um W be use]an a career Mtln aemab0 rarulra Ne mem puchaaed ham
and is Ee¢uLe] as Mines
0%uMenbnE that If Me um la Me mall M MM Ma Men cmmMnJ remains, an additional%ld mrnmew may be send Mtlellmry
di Anum lanWyetpurchaSW. IMyuMer wM tdnoumaNrtl oroMeMi9e MvAG
MineY Cremekry, sell Nam me memelM small In
,,ye✓c,mal
e him rempary retell for delivery
m
Reliant G. hallsheyesedN
Thl¢AUMaketlon Farmwae prasMM by Iwas
Cwnpnebnab Fall Care, Inc
A(Xhill Ay., Sell Spnnga, NY 12M
and is by Me funeral slander as wN95a Wa III
INJe pave remlve] a cmpklad mpy of Mls ANhorhatlon Form.
The deal ldenN below In Me parmun(e)In central WdYpaemon.who by alpnlnO Min AUMmha Form.0N gs)
W me accuracy and complebnme W Me lMarmeNOn cMrlalned In Min AUMandenen From and euMONxe(al Me 1ppgng.
amed Mla 35M "Yon Segmental ,p RO
Came Oaw"nen
318 Gum Ean ee Reed, Ganeevmsl, NY IMI
Mrs,.eyoreffil ease"
WITNESS rmwnrvuw.s� amre+rr�
Rolland G. Hong ll
116
Alban Dail
DOS-18wf(May Mi Page 3 of