O'Donnell, Kagthleen Ann pine View Cemetery & Crematorium
Quaker Road
QuOO"Sburyl NY 12804
(518) 745-4477 or (510) 745-4476
FUNERAL Home. (APEW
RETURN TIME:
DATE S TIME REMAINS ARRIVED AT CREMATORY LI
NAME OF FUNERAL DIRECTOR OR RECRISTERE . .D RESIDENT DELIVER'" REMAIN_S.
- - U#
NAME. K"I uo— O[ OiNN
TYPE OF CONTAINER _ 1 _ CASEN
PLACEOFDEATH: Utier
~
(DN[M
83TIMATED WEIGHT OF REMAINS 8 CONTAINERS
PLACED IN HOLD: zrD--(yr.
PLACED IN REFRIGERATION:
DATE OF CREMATION, - -.. g�— --
TIME STARTED: JI�SI'0 - -_
7`LS/jYG_ __TIME COMPLETE0 )oaf
PLACED IN RETORT ' A--
_.__.._..T QpAn .... _MOVED.
RETORT 11 IN WHICH REMAINS WERE CREMATED: _ Ic i lo'm/11
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORETH
FROM TIME OF ACCEPTED DELIVERY q HOURS
NOTE. TIRGLIFMATHON LOG SHALL O[ np rvInEV
ExmgxLxi [ILE O! TRf [nlMniOpY,
EWYORK Division of olVlgaN OF ow(Y'll"PiTry, iO
of l
Cemeteries •°„^Yt°n„-0�,
nk, dmirl ifu ¢
Authorizatlon for Cremation and Disposition
TWA AUMocogon Form must be command and signed poor to delivery W reaalm for cmrmM .
Data:Vkha ono number: 1092
Crematory Name P,2 Yi Gamabbum '1K
Morass.Quaker Rd..Cussnsbury, NY l MA phone_ id ? -v
CREMATNM IS AN IRREVERSIBLE AND FiM PROCESS.
Door is course ul ce pkarg Me m ,led Ned asW and Me container among the remains into a amended chamber where
they are smeared NInHe hem ant flame. The heat uH Rams All b Jnenb And consumaavanaging eaci both and all
which are all that wo 11 be lea eftsr aemannn.
Following cremation,the remark will lake r amnable efforts to remove all or the remains ant other material hum the rremerm
cLambar.bNwme minimal dust and residue ruin likely be left behind. The cmMe will separab inadental and foreign mabnal fern
the remains and the Incidental ant f rmign material all W dPolwsab of as real Wow. The dammed remain will be mechanically
newel Into small places and plmod into a designated mnmmer dun. Cnmabd rimalns generally am aluminum!Ya rig no
simple fragment Is recognizable as skel l t all
OPENING OF THE CONTAINER
The crematory may only Open the comener holding the uncremabd human remainsin limited circumstances, sc esbwnfmtl
jure
chourrapary memory
human rei cal maineiaina4 11versdnln a maintenance, is net suaebM to might
mMian such asconmomnitl or smallo ed.the
- If
mtlay wilt require that Me remains be mnvst Imoa suitable container before It,ccew¢the remains. The OmminB of
commay or the transferor her of all Mn the conducted before a whams ant all don dare in maary, won dignity and msp .
DE"FCATON OF DECEASED
Name of Drmaeed:Naft a m Alan Coastal MaM l all Nsvrtearted
Law Nnorn Address: lJ Hartford Ave.,Apt. B3, Glens Few New York Inn
Place of Death:Glens Fella Canter, lag Shemwn A N Glans Flats, NY 12MI
Sac ❑ M IDF still 00a.1211V1949 Deb of Death Estimated weghe25011ae
Ds¢cnptbn N crad onminerin which remabu wil W dellvem].
Manhe Casket Co. Cremation Case - cardboard top, plywood bottom
PERSON IN CONTROL OFOSP05WN
(Perwn(a)in mnrM W Nsposltbrx typy ONE wine lalmwinBl
I an kwe am Me designated agent of the deceased damma ed In a will or wrlM1en instrument executed Famous Public
Health law Saatchi 42e10
-0E-
r� INom hawe no knoll Mat Nat bewared executed awMmn nuWmenl pursuant ill Public Health Law Section 42DI or
ing dhealans for the dbpos tom 0f his or her remains ant Yvm are Me mayor)more moony under Public Health Law
Sealen 4201 and have Me fan to mrsew aematien of troy remains 0f Me ddeari ki relationship to the bscaaded Is as
follows
Kathleen Ann O'Donnell
DOS 1i I(Rent. Wlge) Page 1 of s
Authorization for Cremation and Disposition
(InsMfmmmelul5✓ow)
Number oasmptim some,
t. Apsrwn daequesedwrwril pursuenllo Pudk H Mldw$ OnQ01(3)',
9. The me,11195poual
A. Can snMvma domestic wrPar,
3. AM son child eghteen years of ape or ad
4. Asurvivin9 parrnt,
5. A wrvwlrp soling SeMeen years W age w older:
B. A lo-Multrammina d guardian:
). My persomid eighteen years of age or dairy mi W she re in Me estate add who ✓are harder In relationship to the deU Wd'.
a. A duly appended inomery W the edr
S. Adose fiend on a4ve who has Manded a written shalament punuanr W Public HealP Law Seem 4001
10. A chief fiscal officer of a whom or a poll Is administrator amended punuenl to the 8uncgare s court Pmmdum sad
Im. My other Mann who is acting on b all W the decreased and wM has succumb awdtlen statement punuenl W Pudic Health
Law 9Micn AN 1 O1.
G ALL THREE tithe b ddy,mg)
7IAVe hereby dMm Pal Has hotly of the Manuel does nth contain a battery amem peG, power call, cannabis imphM,
or MbaNve devin eM lMl my such materials were sewed pm M Me matterot this AYMw Za ft Form. Failure W remove
the"yItems poor to crammion may result In harm to the rnmatory and cri mXory Wmmnnw.
Me arm Mat InsWcticm have bass Seen to Lawrence 5. Maine
RSamid the removal of any pmwnel pmpeM or deer Ping W vdue which any pecan agree hskwa any family member of On
deome wishes b pmmrve. Pond View C,emelorlum
Innis
ie nW respdmidebr the removal of personal hems ham the mmelner or Mon the remains M the deceased. warm lItems MX In the
Malner An Mth the retinal will the desroyad by His crmMim proceee and cannot be r dt daMr cremation.
V-Welimmbyamhodee Pine Vdew CMMMMum Ic+ruw
W cremab the remains 0 the G us".
MaDid OPTIONAL)
lMv hereby auhon the named Nnwl dlreMr M provide tar Mllwry to and merlon by an tllemaA
adal If Msmed necessary in ire opinion of the fu oral director, and to amend this bear th provide the comfort name and
dress of such alNrnate eremamy.
FINAL omF061TfON
The ninon ou onud b mulve the uemmed remans of ire dam99ad from tie nwoalwy'H:
Name:CMemn Furenmdm,. Inc.
Adders:68 Mein St., Hudson Falb,New York 19839 pie. 5187474243
The aamWM remains W bemawd wJl be diapesadaof�m�bewn:
Moore 818t Me C M Far Ednwrd NV rmrp
If he any brown Me person named above does nit We puswgn d Me cremated remains,
P'me Ne'w CmmsMum Is auffi ed W are puussond
ideal Main
the remains to Cadman Funmd Home. Inc. by Malay
In mlwn or by reglabred mail, pas✓wwIW nMn O'Donnell
W318961(RAN.Iimww Paja 2 of
Authorlution for Cremation and Disposition
hie Me Mummi
.yl IH Me understand Mat if be remNna am m1 wimid which uo Wn or memories,
Fun one Cnammad m may d6{ue aun bananas N
rw✓fix
an Ibe levable manner, goon as by mne,ing,
CREMATION CONTAMERURN
f ONE of(he colrowrng)
An um b be,end as a mMuirer he the moment remains has been purtMvd hcm
and is assumed Is blows,
IM'e understand than Ilene um Is ere I b MAd He entire aemMM rasheiru,an additional dpld innocent may an used for delivery.
L M um h not yM pucnaeM. IM1Ve understand Net it M um is lWMM Inopposed provided
pine Vlaw Crematorium sm place He ammMen remains In
a Who imurzry container for delivery
eseu�+.me
res Aua "lion Form was pmmtet by Chambers S. Maine "a exam at
CeIMon Funeral Nome. Inc. nwenv
nn.e,r
W Main St..Hudson Falls, New York 12839 run con
ends signed by Me Wend thane,as ximess to 1p 9xshomm. Feu
Aide Mva marved a composed copy atma senescence Form,
Thetot a aaau(grmlyIdentified
nd compliances cotes mlomurion rem inaa dimensions
aduu�:errwn Forrmniimmediate)the foneeinng.4n1
Signs also dry of Sept .m TU
����a-tl-ti ari of �7eArr ik �n ; .� �L,f.(no6�
y ✓n VAa b QDnA 1k C/7rn INJGJ'
eesfe
WITNESS: rvunvnww
CassaMn 8. Mallb
10257
feminine,Nhys"?
Kableen Mn OCmMI
003-tme4(Rev. NMI gage 3 03