Philo, Bryan T. Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME:
--- . .._._GATE B TIME RE RETURN TIME _
MAINS ARRIVE) AT CREMATORY'. 1'
NAME OFF
UNERAL pIREGT.yOyR� OR REIG11ry1ST1pIREO RESIDENT DELIVERING REMAINS:
NAME:
TYPE OF CONTAINER p
CASE p
M.Rrol¢,_�.ri 1ZS4 LfIN__suq //6A...�.
PLACE OF DEATH: S Feuf1 yG nn1.P
ESTIMATED WEIGHT OF - -REMAINS 8 CONTAINER . . .
PLACED IN NOLO;
PLACED IN REFRIGERATION:
DATE OF CREMATIONTIME STARTED:
— - - "-
--
3 p0
PLACED IN RETORT TIME COMPLETED:_ I))6 Pn - -----
TRETORT IIIN WHICH REMAINS WERE G REMATEUEp; s-
_..._ _
DETAILED REASON FOR DELAY If REMAINS
WExE C RMUF HOURS REMATEO MORE THAN QE
FROM TIME OF ACCEPTED DELIVERY
NOTE. THECALELATIONLOG SHALL BC RE xInE RIIMAxkxLsLE OF iNE [nEmniOvy
low
Dewmemm rumen
NEW PORK I Division Of DMSIONOFCMUEmES
SO
T TEOf ,ter," scars
OW. Cemeteries 99 W,,a,,Mw Avs...
Tw o°�n:,ewto�m
an,IS one
Authoriution for Cremation and Disposition
"IS Aabnoral Fenn most No COMMa and slaved Push to all ad mi"ror Creme .
Data. 09/1712020 Number {O!D
OTenlmOry Name.fond Mew Crematorium
Aeeaee 51 Quaker Road, Queetsbury NY 128M Phoss (518) 7451
CREM MN IB AN IRREVERSIBLE AND FINAL PROCE88.
Cameroon iscounsel em by aaang Me remains Of the dmaased am Ire consul moral me manufacture a memadon chamber whom
they am subleased mintense hear and wme. The heat and name will Inch.ram and cunume eve g sacept bone and m 1,
which m all thx w4a b r left aftercmmmon.
Following crematem.the crematery art uxe reasomble efforts to remove au Atha rumors and bllwr mewdm from Me crameban
chamber bmsoche minimal duet and moos will hisey be left Poland The memarory well Small madenal and foragn rural At
Me remains and the mademtal and fora) matadel art lImtispdsM of as ma+by law. The amended remains all W economical
pulversed into small mocha and Placed into a tlasignated ¢nbim or um. CnmR romalns Beneraly are purse Small no
sir mere Is recaanNaNe as sx ltluw.
OPENING OF THE CONTAINER
The crematory may only open the wmainer natural that uneremated human remains In limited prcumstarcea, such as to confirm tln
identity orthe demaeed ore,Serum that no marerdie enamel Mich mightinsureemployees or tentage me crematory parody N
human mannatim ere aellvemd Ina con4morsMkh is not sultabXbr cnmaWn such AS ceremonial or rental casket this
mmnatory will des In menthe nmm to,minima Into a auhable comald Wereitacupb Me remains. The ocanna l a
nuiner or the tanner or remdvel mremain sell re mrauctat before.wimem am sell x erne in privacy, sent egniy and mpea.
IDENTIFICATION OF DECFAaEO
Name of Deremed. Bryan T. Phi Nadu Sums: Married!
lam are"Address 5 Fork! Ave, Que iumbury, NY 12804
Nam a All 5 Feld Ave , Qumnsbury, NY 12B04
Sax ®m OF Aar: 31 DDe: 05131/1989 Data a tn: 09/18I2020 EaalmeNdv m:c9ia
Demphm of wsxeumattaimm M whm remwb.sell So dmivered.
N rf Ik N P' La to
PERSON IN CIXITROL OF DISPoSITION Y
formal car commou maspoum,.Adjpl ONF mthe/dkxingl
I amM4 ere Me cmiputM agent of tlw deMafed deeignbd m e sell or w msWmmt ewemmea minimal W Pubic
Health law Modern 4201.
-OR.
ci Am have no xnowedge Mat Me normal executed a written mshumel dursual 10 Public Health law Seaton 4201 ma
will central dbeaions for the dlapomion of his or her remains and INe are the prams)haviiq peomy uneer Public Heats law
$edtldn 4201 ane have the right W eummve uematier of Me not of Its,tettaseb. MylOur mlebonshlp ionise MMaeea IS AS
follower'
Bryan T. Philo
DOS-18Wf IRay. 04R0) Page I M3
Authoriration for Cremation and Disposition
pnxnmun Ma uat Wro
Number 2 Oeamption: Spaced
1. A person demanded in among pureumni Public Heats Awi SymbM201(3):
2. Tre Summing spww;
U. The surviving dw cpander;
2. My sunwirg child eighteen yin d ape in Oder,
4. A surviving parent:
S. A survimp stuhng eighteen years or Laws or Ober.
6. Alewrult)appointed guardian:
T. My demands)abnldon years of ape or olden entitled to Whare In the el and who ierare consent In headmHq b the dreased;
B. A due appointed fiduciary Of the estate:
8. A dose Mend or mime who has eaecNM a Much statement WrOnl to WGlc Health Lax Section 4201(7):
10. A Mlet fixgl otter M a county Or a Wtdic administrator Movement huffish to the Suriname Court Prorodure Ad'.
did. My titer person who is udrp On When of Me deceasM ant wad has exrruled a written statement WrsuaM to Public Heats
tgw$eMnn 4201 p 1.
unwdA1 THREE of Amusing)
IMIe Mreby affirm Met the bi of the hou a ed down not=ra n a battery bri pad, power Poll, radioadva imdand
or radi0actow device and Mat any such mO nals wxe rempred prior M Me execution of this Measurement Form. Failure to numerous
Maine items poor b cmnabon my muh In Nmt bvie anmebry and cnnutary p corm.
Me affirm that inumvtamhave Wen plum to Wend Butch
rate cim Me removal of Any pe Poi propere or oMx Wnp 0 vom which any persn signing below a any feMe member of Me
dismissed wishes to preserve. Pine View Crematorium
R .m
,s not respansme ter Me removal of"=net items tom the container or Mon Me remains of tln de[eaeed. Pananal ifxro MM11nda
container or wits Me Opinion will W destroyed try Me cranution pence s ant cannot W Mounted ant champion.
Imp Fenny summoner Pine View Crematorium
la.v'wAr mcnanam Me mmaw ant.e.Wwew.
(mitt (OPTIONAL)
IMe Many subsidies the named Nneral Ommor to proide rot deliveryto and arNWtlon by an aRemro
Colossi If deemed necessary in Me opinion OF the funeral director,ant to amend this fmm to provide the mm01 name and
address Of such aX ge crenni
The persom sulWrivd to modern Me cremated mains N Me dnwasad M1om 6m cremdary is'.
Name Real Denny Stafard Funeral Home Wendy M. Bul'cth
Address; 53 Quaker Road, Oueensbury. NY 128N Mime. (518) 792-1114
TaueriyM moral Otleuaeed wal W dapaad d stations
Return to famnify
rcW my tenon Me Pelson normal Move dose My any,ponaemMn MMow addressed mayor.
Pine View Crematartum :wuMa ghmpo sionot
mmwn
gw remu'n'ab n Regan Denny Staford Funind Hone by Wllvary
H pwson in by reglmered and. p�m..mw Bryan T. Phib
O0S1896f(Rev. MRo) Peal
Authorization for Cremation and Disposition
llumelme WbnvnpJ
IMb uMnslana the)Ftte emMna am M named wlMn tM dote adiamonds,
Pine Yew Crematorium may dmpow of ga moment in
an imtmvabb manor .such as by svMdng. Ne,woaun
CRV%WdONL TAINERNRN
)mom ME dine foRni
M um to be used as a waaimrbr the wmaNa rtmaim Ms been ForWxd ham
and m dumbed as forlorn:
IAlm unaentan l Met If the um is tm Small to now the mare uenMM someone,an e3Feyul Apia container maybe used be aNrvery,
oR-
'!R nnumlanmyNputcheeea. pweumamma MMnroumlewmhaeedarm wPmN
Pine View Crematonum win Maa,the infnmted demands in
rvM✓ten
a night lempomry carbonate for Memory.
This Awtwvden Fort wn provided by Wendy M. Bulich urea e.xureaM
Regan nanny SteBpM Funeral Home
53 Quaker Road, Quessmstai NV 12809
p.tire..au.e
and b ei0ned by Me formal director as wllmM to ib eveMun.
IAft theme received a mandated copy of Miz AUNwlvtlon Farm.
The Wmonlq ImntMM Moscow Want Me perform)in control MdMposltlon,who by Mgning the A~bwWn Farm,ebesga)
to Me accuracy oral completeness 0Me Interested contained in Mis AUMMfaatlon Form and auMwlvts)tM bnagot
Signed this 17M dq di Septembef
Samantha 1. Phiki yt.,Vl\T�,g n
159 Pitcher Road, Quaenabury, NV 12800.
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' nwerwarw aMe�
W ESa:
Welly M. &dkh
R.+wamnwo.r.rw,w
10461
Bryan T. Philo
fasar
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