Bell, James B. Pine Virw Cemetery & Crematoriur-ri
Quaker Noacl
Queerisl.)ur'y, NY -12804
(J '18) 745-414 / 7 or (` -1 0 745Y
44.70
FUNCRAI HOME.:
Pt
DATE a TIME IzcTURN
TIME:
r-:
RF.MAIN:i ARRIVED
............ .
A CR1.:
MI\l OH ��IZ7v pyi
ZME Of r`UNF_r2Ai. fltrZt_Cl'O/2 nrt Itt Cltl"
NA /' �
,TErtCu Il1_SlDr
N'r DELIVERING REMAINS:
_
NAME;
littas L
TYPE Or � Ci\SE IIC CON r A I N t_r-t. he a:�1�(. ... ( ici ,,Nr_ 6 ��Z to
.._... NY wood t n
va
PLACE OF
(70 r ......Stilt r
ESTIMATE() WEIGHT' OF
-
REMAINS
& CONTAINUt _.
PLACED
IN 1{Ol_C). l �S�tQ
......... .
ACED IN RE:1--RIGERArION:
..... _.---_ __...-..
DATE Or CREMATION:
_"
TIME ._.START' f�
V�� 1-IM1=. COMr�
t_C'. t t tl
PLACED IN Rr T'OR'1 / ,�
is
RC1'ORT (! IN WHICH REMAINSW ��
C I1F CI(LMA I ED. j� ww�- ,
DETAILED 12�ASC)N FnR r)f-'.LAY Ii IlHMnINS wr-rti_ ` P��" ;-......._...........__ ...
tIMATEp MORE THAN 40 F{OURS
FROM TIME OF ACCEf TFD DI-LIVERY.
..... .............
NOT :.
l. TrIt: Clt '
..................
ION - __
LOG SPIA1.I III; Ill: I AIN,_ •_...
( 1) IN lltl: P[ItMltNI. N'T' I'llC: or T'llf CN(iMnrUrlY,
F rorg+: NHC Reception Fax 1 5186233416 11/27/2020 10.09 #875 R.003/005
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!+air Ycrk Birth
T.—C-41wYORK Division of mod CEMETERIES
SZSTI Of
411" "" Cemeteries °"` `��"tt
Avcnutt
Atir. tr {tom,,.
Tom : 4144226
wrr+rsikri r►y.wv
Authorization for Cremation and Disposition
this Aughori ettan Form most be completed and signed prior to drativefy of masks s for cremation.
1 t2O
Number. 11-1.10
Crematory „o:Pine View CrematoryNe
_w sees
Quaker hood.
Dueensbury W 12103( its-t77
CREMATION$AN IRREVERSIBLE AND FINAL PROCESS.
Cremation is caned out by piecing the Mallar41 of the deceased and Inc container holtkrig the remains late a au on chamber where
they ere subjected to intense feat and lane. The heat and flame wit incinerate and consume everything eiecopt bone and metal,
which are ail that will be left alien cremation.
Following cremation,the c:aemmory w41 wire reasonable efforts to remove ail of the reme ns and One(materiel from Me crerrakh
chamber.but some minimal dual and residue wit likes/be let behind. The cre nstay via separateincident*and foreign material from
tree,tern-suns and the 'tridental and foreign material vet be disposed of as required by law The cremated remains veil be n
pedvenzed into arrueil pates and eared into a designated container or urn. Cremated remains Senerally are ptdveitzid Lentil no
single fragment is reciognimbi►as skeletal tissue.
OPENING OF TNE CONTAINER
The exertudorr may colir delta the cords sr hailing the tm-crameaed human rams*in awaited oroonstaances,such as to seder the
identity of the dammed a to snore that no materiel is enclosed which might injure employees or damage the crematory property_ If
human remains are delivered In a container which is not suitable for cremation such as ceremonial or rental casket the
crematory will require that the remains be moved Into a suitable container before it aeoaptt the remains. The opening Of a
container or the kr*rhstsr or removal of remains will be tared Oefore a witness and—ail tie done in prima,with oignay end reaped..
IDENTIFICATION OF DECEASE'?
El Roe Married
Name of Deceased fitatiai Status:
17t1 Mien Si.,Glans h`atac.NY tlatli
Last Known Adore»a-
I he barons at Glens Falls, 170 Warren St.,Gians Falls.NY a 2110i
place of Death:
175
Sox it NI D F Age:95 D08:081 &'1825 cafe of Death:1912 2� Estimated ilVasghi:
din of caesbctiC er in whirr remake wia be delivered.
MacDonald Container- Basic cardboard cremation container with wood reinforcements
PFRSQN IN CONTROL OF Dt8POSfTlo(
(Persu afa)#COOtro,of art: ;ONE of the ralotrolyi
3 arrvWet aro the( nerd agent of the deceased eta wIM ot%TAtWR inskti meat entailed pnsraraant to Pubit
tistth Low Section 4201
in%have no knoviiedgei that the deceased exryrutod a rv.there instrument oursui nt to Public trea.`lf Lew Section 4201 or>f
ralinMining crew:dons for the dispordiort of his or tser remains and Wm are the persrxtts)having pnon?y under Pubic health Law
Section 4201 and have the right to au:horde aerrntiat of the remains date deceased_ filyfOur relationship to the deceased is as
follows.
James B. Beat
_.,_ _ .._ :, ... _a,�_ 0
DOS 1896-r(Reit 14'20 Page 4 of 3
Fr Om.,eINHC Reception Fax 1 5186233416 11/27/2020 10.09 #875 P.003/OO5
•
fiegicYcskStott
Depertment cif State
er—drINEWYORKC Division of DIMON OF CEMETERIES
t:Tu11 OF Oft Coyne a/Co Phut
" It Cemeteries 16 Aw
A xwp,f4V`t ntriCOt
Tee o c;t3183 474422e
Authorization for Cremation and Disposition
TNs Authorisation Forth must be completed and signed prior to delivery of raanat a for cremation.
/1rze12020 1 L'1Iv
Cats le umber:
Pine View Crematory
Crematory Name
Quaker coed.OUeeerttbtey.NY 12404
........ ,x. .......-�._ _
�t 6.74t'S-4477
Atiereto i'f►crto:
CREMATION IS AN 1RREVE*S18#.E AND FINAL PROCESS.
Cremation is carried out by placing the remains of the deceased and the container mil the terra inS aatc a ae<rtsabon chamber where
they are subjected to intense heal and lames. The heat and Same will incinerate and eonsome everything torment bone and meat.
which era all that Will be left alter cremation.
Following cremation,the minatory wits take reasonable efforts to remove o$of the reeled*and other maiseneet from the crf nMon
thereat,or*some minimal clue and residue wet likely be let behind. The crematory wit wore&incidental and fort*/material from
the remains and the incidental and foreign.material will be disposed of as required by law. The crerr.ated remains iatil be mechartically
pulverized into small prates and p'ward alto a designated contlin.er or urn. Cremated remains generally ere pulverized mitt no
single fragment it recognisable as skeletal beaus
OPENING OF THE CONTAINER
The c ent>atoryi may only open the co:Valves folding the to-ciremeted human wrens in knead CSeCtaelttleleet. as to confirm the
identity of The deceased or to ensue that no materiel is end which might injure em oyees or damage the crematory property. K
human rename are delivered In a COntitertOr winch is net stAtabie for C1.01a0on such as Ceremonial or rental casket the
minatory will requires that the Meek*be moved into a suitable container before it accepts the nrmains. The opening Of a
container or the ken de'or removal of rnmane well be conducted helots a whose and be done in privacy,with*ray end reapeoi.
IDENTfi!CAT1ON OF DECEASED
James LI Boll Mauled
Nemo of Deceased „ , Mahler Status:
1 TO Wren St...Gem fats,NY t8Qi
Last Known Addreess:
the Pines or Glens Falls,in)warren St.,Glens Falls.NY 12 0t
Ptacc od Detlh.
F sneer elm C� 95 08/0811925 1112512020 175
Ago: DOS: Deno of Death: Estimated Weigit
Description of caslitticorditiner in which rernu s wt be delivered_
MacDonald Container Basic cardboard and cremation container with wood reinforcements
PERSON IN CONTROL OF Ot8POS1/1 j1
(Per res)in curd of tespositiortidgiCWE of Me turner ing)
aseillee area the desigetawted agent et the deceNasEd desolated me*I at%Truer thsh rhrou dxeetdoo porstolot to Nodes
Hearth Law Section 4201
f1`
hate have eo ktr:Wedge that the deceased executed a*retell instrument pursuant to P l Lew Seaton 4201 or a
.:` specters tsar the tf tpo sort of his of neat remains and t vm am the pi t)havlrrg priority under Pubse Health Law
Section 4201 and have tea right to auiho a cremation ad*remains of the deceased. StylOur r elationahip to the deceased is as
follows
James B. Ben
poS 1f96-f(Rev 04 Pagel of 3
Fror:WHC Reception Fa. 1 5186233416 11/27/2020 10.12 #875 P_005/005
Authorization for Cremation and Disposition
•,OF
= understand at if the remains are not darted within 129 days of c*um&on,.
Pine - remalory
....,:_._ �: _ may dispose of the amainrn
an irretrievable mar such as by scattering.
trfli AT t coerrA$HEamet
1 ONE drraeiirifowery
Art 4+n to be used as a cnneelner for me rraaheo re'rr w has been INgenneed keel .....:
*Ad is described as follows:
IMV* that tf Me urn s!trio small to hod to entre Chem to t remains an additional nold container may be into for delivery,
-O'
„rn is not yet purchased undeispieral that if no urn is purchased or otherwise provided
Pine 97 Crorrratay
. '+ ohm the cremated remains in
a raid temponey container for daffy.
Patricia Miler
Brewer Funeral Horne, Inc
24 trs i 5t.Lake Lulerro.NY 12846 ? +
tG�rinr'irnr1+ast
and is signed by the Wane director as witness to its we on.
tMre nave reamed a c i npteiee copy of rAte Asithornaeon Fenn.
't a persons)identified below is/are the passage)In control of disposition,who by signing this Atahorizabon Form,attain(s)
to the accuracy and complaining*of the information contained in this Aptherization Farm and authorite(s)#Ire foregoing.
26 November 20
Signed this day of .20
fad B
�xaota M+►haslVr+a At2+LL p1 r o)
2924 Worth Shore stood,N$dley,.NY 12835
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tiriTtrwss:
Patriot;Miller•
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12465
,lamas B.Bea
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oOS-t89e-1(1 e+ 044201 Page 3 of 3