Hubbell, Richard Lloyd Pine View Cemetery $ Crematorium
Quaker Road
Queensburyl NV 12804
(518) 745-4477 or (518) 745_4476
FUNERAL Home. ___. DAMAtut
DAM .... .. _ .. RETURN TIME Iwrrp
DATE S TIME REM41MS ARRIVED Al CREMA LURY', yy�II
NAME OF FUNERAL OIREC TOR 91eg1�—Z ^'(EI OR RE4RISTEPEo RESIDENT DELIVERING REMAINS:
NAME:
_ - - / 'I _. L •.(. _TYPE OF CONTAINER, _.. CPSHFr�I _ d C*rYr
CASE #
Pat J K__ hPEfpl K 3saog
PLACE OF DEATH: �4pn' --
ESTIMATED WEIGH ! OF REMAINS M CONTAINER
PLAceD IN HoI.D. _. J. _8D
__AP
PLACED IN REFRIGERATION: - -
DATE Df CREMATION' --'-
TIME STARTED: . A'HL TIME G
. ._ 1
_09�8
PLACED IN RETORT _'IUi JJ I2O AFLI
-� - MOVED p��L� 2A/gq
RETORT E IN WHICH REMAINS WERE CREMATED. (OONN/ I�-
MOyF
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 4B HOURS
FROM TIME Of ACCEPTED OfiLI V ERY:
NOTE
THE
mA RON LOG SRALL REn NIRE NUIMAN[NY FIE E OF THE CREMATORY.
Authorization for Cremation and Disposition CuxtCAiris
One ram�ra here. .lersa
wFw.ua:m
aw.,Avant so
nh AllMmhaaoa Form mw "eonjugh dmdsig Wpr by national of re Ws McwN m.
Data: 9)r)w Number
Crematory Name: Piney rw Crem N
Address Olmkar Road, Commentary, New Valk 121 Phone: 518 T45-44]>
CREMADON 15 AN IRR"EMIOU AND FINAL PROCESS.
Cremation is carried out by placing the remains of the deceased and the container holding the remains into a
cremation chamber wheretbey aresubjected to intense heat andflame.The Nelson m M1 and fla will moderate and consue
everythirg ee bane and metal,wMGi are all that will be left after p madan.
Following c re matio A, t he crematory will take reasonable efforts to re move an of the re mains antl other material from the
cremation Chamber, but some minimal dust and residue will likely be lent behind. The crematory will separate incidental and
foreign material from the remains and the incidental and foreign material will be disposed of as regNred by law.The
cremated remains will be mechanically pulverized Into small pieces and placetl into a designated container or Are. Cmnated
ribrujims generally are PUNeri zed umll no single fragment Is recognizable as skdetY Nzsue.
OPENING OF CONTAINER
The crematory may only open the container holding the una'remrted human remains In limited circumstances, such as to
confirm the Identify of the deceased Or to ensure that no material is enclosed which might Injure employees or damage
crematory property. if human ranges amdelFmred in a cantainw which is net smtable for ua Wn seen in Ceremonial or
e n rental casket,the Mory will require dust the remains be moved Imo a subable container before h accepts Due mrahm.The
opening of a Container or the transferor removal of remains will be the noucred before a witness antl will be done in Privacy,
with dignity and respect.
IDENTIFICATION OF DECEASED / I I I
Name of Deceased'. � C ltr� L 'l/oze) ,f�ct. L E. Mama) t 1 Statul Fcl
Lam Known Address. 26 qa di r0 cs Q �iP NI
Place D(f�Oeath. L ,.�IJVAM ti�rn Ca„-, Ft� �du<�-d Two O
Sex, Pm of Age: e3 OCIB: 1]/g( } oateofO h: a a� EmimMedvityl
Description oftasket/container in which remains will be delivered:
Corrugated Cardboa d Box with Plywood S[ rmark Model N 38US
PERSON IN CONTROL OF DISPOSITION
IPersonjs) in Control of dispasnlon, initial ONE of the following)
I am/We are the designated agent of the deceased designated In a will or written instrument executed pursuant to Public
Heahh law section 4201.
-Oil
Q ppJJ I/We have no knowledge that the tleceased executed a written instrument pursuant to Public Health Law section Q01 or
y .VcgontaIning directions for the dispergion of his or her remains and (Continued! next page)
krdrwdf LIOYJ K4j�Lell
s l8t si sks, Curial same ytwmN ewe 241
I am/we are the persams) having priority under apple Hemx Lawseetion 4201 and have Me right to authorize aemadon
of Me mine Ins of the deceased. lifivi rlbOomnlPtoae damagN b asohmes:
(M¢rtfrom the lot ONawf ('
NumbarA-0ascmpgan: lay,�e.
A person designated in waging pursuardM Public Health Lax andson 4201 (3);
0 The summing spouse;
U. The surviving domestic partner.
3. Any surviving child eighteen years of age or alter,
4. A surviving parent;
5. A surviving sibling eighteen Were of age or older;
Is. A lawfully appointed guardian;
T. Ally persons) eighteen years of age or older enti0nd to share in Me estate and who ishere creep in
relationship to the decease0,
B. A duly appointed fiduciary of Me estate,
9. A tlme Mend or relative who has executed a wishes statement pursuant to Public Hearth Law§4201(7),
10. A chief fiscal officer of a county or a public administrator appointed pu sal Me Surrogates Court
Procedure Act;
10a. Any older person who is acting on behalf of the deceased and who has executed a wdsen statement pursuant
W Public Health Law§4201(]).
gaUN ALL THREEO1tMfollowirgf
I/We hereby affirm that the body of the remained Mass not contain a batery, battery pack Power bill, radioactive
planq or radioactive device and that any such materials were removed prior to the exertion of this Autbotiradan Form.
qF0llur'e/t0 removetklse Items plants cremation may reps In harm miss insurers and mergers,plrmMll.
l E pWe many affirm that instructions have been given to avers ssa mm arr�ker p1o159efs regard'mg the
moral nl
VX of any personal property or other thing of value which any person signing below or any fatuity member of the deceased
wishes to preserve. 4rememrvmmel Pine View Comp not responsible for removal of Personal
items from Me container or from Me remains of the deceased.Internal left In the container or with the remains will
/dJe tr/ave/d by me criterion erocea and started be banned after caused".
lam/, (/' I/We will auModre rmi to crampar dre remains
e deceased.
HNALOg`CSIJ d1
The person summaetl to receive the cremated remains of Me decspesed from do crematory is:
Name: Baker Fungal H Peas nit I
Address: 11 Taftevelthe Stragard. Quagenslaury, Name York 12904 Pineal (518 151-9303
The cremated remains of deceased vnll be disposed of as rolipws:
Return to family M be canceled
If for any modern Me person named above does not take pmsession of Me cremated remains,
tmmnw s autlgnzetl W give posesp eon of the remains M
dpmmmwnmmel Baker Funeral Home by delivery In gotten or by registered mail.
R l Ldy� HN bbe��
oosawer-ilae..ourm wrvwwad Finapa
lays understand Mat i1 Me remains are a dNrraaawdhin 130 days ofcremation,
ron ,,m) Pine Y Crematnm may dispose of Me Rmalns in an 'Inatll¢vaGe manner,
uch As by scattering.
CREMATION CONTAINERNRN
(tn=f/ONF a)@e)o„owing)
An urn to be used as a container far Me cremated remains; has been purchased tram Baker
�Funerel Home and is described as follows:
IWe understand that Rthe um is and small to hold Me sire cremated remains, an sddibonal ngk consumer may be used
for delivery.
Cfl
An um has not yet been purchased. We understand! Mat R no um is purchased or otherMu provided
.ire) Pine View Crematory will pless Me cremated remains in a ni temporary
container for delivery.
This Authorization form was prunded by aw,.w.ti .mF, l,p $S q n +.++�/'?�
wasexerutadatrs,,,swk, , Baker Tuners A
punwwhon..may ate S O b end is asked by Me Mneral director
as aiMess to Rs executon.
INVe hays received a completed copy of Mis Authorization Form.
The laerson(s) menthoad belay is re Me perazi in wheal ofUiiomalson, who by signing this AUMomselorr
Form, adest(s) to the accuracy and oampleierress of Me inbmlation o trammed in the AUModzelfon Form and
aurnadrefsl are foregoing.
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Funeral Home Read W1130
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