Gauthier, Michael D. Pine V'F` v Cemetery $ Crematorium
Quaker Road
Queensburyl NY 12804
(518) 745-4477 or (51 a) 745-4476
FUNERAL HOME; _ ___ ��,�y/MpASL, RETURN TIME:
DATE A TIME REMAINS ARRIVED AT CREMATORY: L �
I
NAME OF ruMeRAL DIRECTOR OR RFG -_4T
RISTERED RESIDENT DELIVERING REMAINS:
-- nz pumaNAME, _
N:CNgA� _ 6gOT{{�_ -
_ /Of$
TYPE OF CONTAINER CASE
� ` `yFy(� ---pl�./y�
PLACE OF DEATH: _ _... IGl (GRGowo
dN(NMkPO-__Kg4p)
ESTIMATED WEIGHT OF REMAINS a CONTAINER /IAA
PLACED IN HOLD:
PLACED IN REFRIGERATION; -- _-- -- — --
DATE OF LL rOrn
CREMATION: '-T- -----
TIME STARTED: "-
__. /J74SRA'1 rlmE com
PLACED IN RETORT. __07_YT/TlVt
_.. -.... MOVED-
RETORT II IN WHICH REMAINS WERE CREMATED. Sy",//-�&/ i �
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED k1O.
FROMTIME OF ACCEPTED DELIVERY' MORE THgry AB HOURS
NOTE. THE
bNOFCE ,a�,:
is
EW YORK Division of OIV51gl°Elam firm
44TEOE mmwre neat
°F Cemeteries ;99 WiliO ool
T.N m�%Idle,4ALOM
Authorization for Cremation and Disposition
This Iwnoidal Form must be ComPletad and signed per to seldom of Moraine For onmas«r.
Date.. s24- 20 Number 1069'
Cremekry Ham: Purainew Oremmpry
Address: 21 Quaker Rom,Oushos ry,NY UPON ply. (518) i<SMri
CREMATION IS AN IRREVEMISLE AND FINAL PROLES..
Channel I5 haled our by them gw morn mMe law am her come holding the remains Imo a mmwon camber when
they are Subjected to heal end fame. The beat and Sam "I lncimmm and consume eaeD'Ming ammo bone and meal,
which are a1I roan wl11 be left amr cremation.
Folkwing cremation,the Cremamry win tabe reasonable edorre to remove al of Nor nmaea and Peter material al me mmaeon
mamder, but came minimal dust and residue will welt'be ten bebind The cramakry wilI separam incidental am been maMlal Man
me remainam the Incleemal and krggn maten.I w:X bat dispose mas redwr.d by law. Tin« aledmmaiMMllbem wlk
pnlsrenzm Inm Nnaf pnwa am gated imodlsyetwad wntminr«um. CrematadremainswneniyampuMrM uMlnp
single aagmem is nwgnirable a aamwl issue.
o ENING OF THE CONTAINER
The pe adery may only dean Me container holding the incidental human nmNna m limier documentary entary such as to mnbtm tln
Nan4lypltlelemJsed orNensure mat no mabnel l5 endp5ed wbkh migMinlure emeloyee5 ordamage Ne uemelpry pmPoM H
human mein an dellwred In a mmatner which Is not uitable for cM "on such as wnmomal or rental weW4Ne
rtmatomx ll dowers nM1Na remains he moved In ea suitable co minaberon ibccam ad&reman¢. The openirg of a
wmainerormeinmlm Prmmoval PImmama Muoawnducmdbe maw ssamwinmlone In Privacy,wpmdmeyamreademb
IDENTIFICATION OF DECEASED
Nana of Deceewd. MitlW D.GNMW Mami hatum Mamm
Last Known,Address: ME Manchatd Rom, GaMevmR NY 1201
Ihen m cash: Ed Marcham Road GanlWo'L NY 1201
Nam 17M OF Ads: (o3 DOa. I - U- S - wMm De.a. -C3 20 Estimated WxigM Jdi
Dewlpmn of asset inwinwhich mundane"If on deivend. //�� �� �� / 1/ j /_
Cardboard Box vaWooden Base wl^� , &O-A0242 P
PERSON IN CONTROL OFDSFOSTN)N
(Paapt(sf NCMhd NILWSG«t ggIa ONE ra me brmang)
I anMRere me dwigndmI agentMdiedemaeed dnignaad in a MII awarded imhunameaecuM ormanlle Public
NAM Lea Season 4201.
R-L
�+ IAme have no moral mar the mcwdlwained a Whind ,Michael at parent m Polk lbaM Law Simon 4201 ma
will wntinirq drxW' s M the dsp on of his or her remain am India are me paryi bating pdonty under Pudic N MLaw
Cecdm OZ°t am harB mergMlo aumOr¢e<rsmadon dl Neremaine mine demaeM. MyMurrabadnshlpMeed "Sedbus
rollo
Michael D. Gauthier
DOS-Lecbf(Rev.WC) Personae
Authorization for Cremation and Disposition
onaan(mmmaxareaow)
Number T Desmpfinn: Mm Gaather(sp ")
1. AMmonaespnateo lnwntingpu*usMto PubUc HaaMlar. 3e4NI(311
S. The wnrving names:
b. The au visa domestic partner'.
> Any surviving Child eighteen"am of age or Clear:
A A moving parent
L A Novlp sl0ling elgamen"am N age or crash
& Al awfully appointed guardian
L Airy Pomon(sl eighteen years of pee or Older m to shore in me estate And Who Wary tlaeY In additional to the dew
E. A duly museum Muclery of Me atei
9. A tlas Maud or relarve who hm exe awman sb M punuanl to Pudic Health law Suchn@01(7),
10. Acirel fiscal officer of a wunlyor a public administrator a(polnRa pursuant to the Surrc a( Wrt Plcmaum AN
1W. My olhnr person who 15 Wing on behalf of has Oa sa and who has executed a whiten eta wt Mmuwt b PULYC HaaM
Lax seelyn agmp).
(f AU THREE a the hcowmd
namcy affirm that the iloay Of the d W deals nM eontam a Aden, tamry p Power®llreIWO"'meant
or redwtlive Mrs and hat any such MWk b were removed pnw b the Imac ra n of His AUNorheaon Fomr. Failure As manages
Men Nepal priory WMWCn may result In harm So Na material AM cm 2Mm Elemental.
l
oomu A affin Mat instructions;have teen given M Holland G. Hoeg
reaming the removal of any cemmal popery or other thing of value which any eamon sassing below wary,hmily raafter0
devoa wool to pmsnw. Pica Vlewcmm=m
Qwwi
is not responsiole MNB mall of personal items man the uxlbinerortNn He remains order deaO9 Penomlbmee Mn
Oon� m a/h,rer Or with Me mnalm wall W demon W tin the methanol pmceu and cannot hey rmae.W afar cmmemn.
�4 pure htimbr alruorhe Pirev�cremmory
w empaae the remews Of the aeaas.a.
(feral OPTIONAu
Ihaa heresy amhonm ma named fanerel ahmMr A physics far ammery fa and.mmmon by an ammee
—wry, removal. n deemed In toe Opinion Of Me Nmml director.and W amend dom fam a r provide Me Cannel name and
.names a such alem.m cmmserv.
FINAL g5P 91TI0R
Tfop NMixd to receive the cuumned rem&M of the dewed from 0o mmmq a:
Hams'. CCmpae& Funeral Cam
Adams: OM Mapb Ave., Smarye Sprigs, NY 12M Pho r: (518)youi
Ttm awnaed remains cfdea will oe dlsy of"homes
RETURN TO EMILY
If he any asset Ga me named d had ach p06WFal tlNe o WmmNna.
mmM CremNay b wHaamf to gM fnmownM
area
the mma'meb a�v C011gmM Fureml Cue. lrc byr hF q
In psi Of 4 re il9 all, Puww wan miM D.Ga.MiM
DOS-11 f(Rev 0 i Pe+u Page 2M3
Authorization for Cremation and Disposition
lrxa( Me lnNo -wag)
untlMWM Mtli11M remains ere not tleime]xMn 1R0 NK MUBmalkn.
Pine Vew Cmm may Mime dMe remains in
an inebereele manner,$1M as by su nne. iw.,.uc.mnn
CREMTION CONTMNERNRN
((pm@'ONEdMe MpawMM
M an to be uW as a Wmener WMe oeml demand and has Mn WreMae'J ymm
and is tleemEed as kilo"
li moerabM Mel NMe um inb r small b hold tl9 FNre eRmeMd remalns, an afthorel rgid container may by used WMOirery.
a V/—MumWmS pur&ae 1. lN undembndittg wum,s Wm edorWMmtaepO
Plrea Vew Cmnamry will pars tlwn Wr 2hSin
✓c..usr
a add bernpowarry wareannor Mr delivery.
The Autlwrzrtn Form vv pro try Rolland G. HOW any aYCUW at
yhrml
Compassionate Funeral Care. lnd
42 Maple Ame Saratoga Sgy9, W 12�
and is signed W Me bnerel daedw as wNeu Diu Ideal ve
li have remlvnd a wmplNM baby,of Me RWwr ne Form.
The pare on(()Wo"M ENow elan Me PorsonIFI M rol dd Mon.who by signing thisrluMmUatlm Form.adeags)
rage u yend convolutional MMelMoema/Myrd canMined In bill Authorization Form and au or s)Ma foe lrg.
Signed Min 20M day of ummwr M20
Myra Gal
SO Slarcrand Rpd Genaernon, NY 13SS1 6
deal
Miami
MMESS:
Rolland G. Rwg
a 116W gexmminmme M^e°u
Mddeal
O.OUMb
OOS1998-f(Rev. 0420) Page 3 of