Homestead, Ruth E. Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: BPtWEQ RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: //Z b/Z1 /0 50 0
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
NAME: R UT}4 komiST AID CASE # 7 Z
TYPE OF CONTAINER: Ai(00A.:101 bos; ro- fs,ntr nv owior
PLACE OF DEATH: The titi PCE C EIvr
ESTIMATED WEIGHT OF REMAINS & CONTAINER fsn
PLACED IN HOLD: /1.ID 41-1
PLACED IN REFRIGERATION:
DATE OF CREMATION: 112 6 i ZI
TIME STARTED: TIME COMPLETED: 3 :10 0M
PLACED IN RETORT: MOVED: L.16� 3' 0S f 7
RETORT# IN WHICH REMAINS WERE CREMATED: fotom
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE:THE CREMATION LOG SHALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
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DIVISION OF CEMETERIES
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rx Cemeteries
~^� ��N^Nes
Authorizationand Di.A
— for Cremation-- ' hor c�mmm�
This A�hodz�don Form must beomnp��dmnd signed pho,u`ddmwrynfrenmans . �
�o25'�2O�1 Nv*�ec- _---- ---'-- -----~--
--- Pine View Crematory
C,em,�»ummeme ---6---���2���-- -- p�one ----------'
�uoxer�dOu�ena up^
Adgreos ___________
[----------C mEMATON|S Am IRREVERSIBLE AND FINAL PROCESS-,niner --
/ner h�di«g�e ���»s
�oon.aoar'edu\byP|aonQNeerra|n»(�thod c�auevmnd �ec � thing except
bone and
unwund
r m�e
nexare
.
Cre' heat and flame will incinerate and consume every
Thethey are a«�s�edt� n�n�e heal and flame
wh�h�*mU that will be left after cremation. all o�e,mele .|a�rmm'he �emna*cn
,enxcwe na�nai�or»
wiakeeayon��oe1o�a*o mo,y�`8meparaieinc}denaond�e
FoU�w�gcrema�on—`xemem�o / | Txeonmm �ema:ed"amoms will bennmchanina\�
sid�ewike ��ehi .
chamomr.b�snme' n/madw$mnde cas required hy\aw The
the nennamsand the incidental arid foreign mwKbe d'ap«we, u'urn �memam*d remains generaUyare pu\v*r�mdwm«! no
puwevzedmmsmoU�ecmnand�ecedinuoade*/gnah $ <'�
) single fragment is recognizable aaskeletal tissue
OPENING OF THE CQ_NTAINER nces,
-- such asoc*ntinnthe
n,,atony property If
may Only opej,the con
dently of the aeceased oc, not suitable for cremation such as ceremonial or rental casket,the
emains are delivered in a container which is t accepts the remains, The C!Pen1r19 Of a
human r ry will require that the remains be moved into a suitable container before i 1 I ,mth,'Jignity and Fewect
IDENTIFICATION OF DECE&SED VV/dovved
Ru1xE. Homestead tvin:/a\ ststoy ___
Name of ofDacemswd
� �l�R.drewnwi Lake
2�-_8e4
_g6
Last Known Address
The Yan'CnCenter Quemosbury, NY 12804 _
_
_____-
P|a� ofD*aVni
_*__
t
92 91113/1928 Daje�ofDea _ Es��m�dVVe�x�
Sex 0Kx 19F Age DOB
�es ,*�oncfmsxe�oo�inerm p�n�
McDonald basic Cremation Co0|@iner. 0V interior0W�ornho mxo*`/.g/
PERSON IN CONTROL OF DISPOSITION
ofthedo"emseu designated maweorwnoenmutmmentexecu�d�u
�ethe designate
ealth La�Section420)
OR-
|� ehav*nokno�|edgethu,th�deceaaede*e�u'odaw �enins�umentPv,suonmPub|c HmabkLaw Sechon4201 o r
_a
/�na d �e � mvm0pvo/�y under pub1�Hea\\h
osfnrU �� pooih»
mU|o��ain m »ofhis»rhe' msan
e'naU oiiheramammw'he deceased MyOu, pnemomwn/ptn the deceased omms
Secton 4201 and have the nght\oao\hmizeo
follows: Ruth
E Homestead
---------- -- --����7��,.,"��---- -- --^- -'--- -
PiA0e 1 of 3
,
'
Authorization for Cremation and Disposition
0nserlhnrT the fist below) son
Number_ Description�_
1. A person designated inwMing pursuant ha Public Health Law Section 42O1<3):
2. The surviving spouse:
2w. The mumivingdomesficpmrtner
1 Any surviving child eighteen. years of age or older;
4. A surviving pomnt�
5. A surviving sibling eighteen years of age orolder
8 A|awf ��oppnin�dguardian, d
7' An ~ i h of �� | h estate d h i�ann closest in oe|sdionship�o�hed�cease �
. yp��on(o)og eighteen ayecru �ren0�eU(nsharn /o�the an who
B. A duly appointed fiduciary of the estate
'
9. A close friend or relative who has execuied a written statement pursuant to Public Heaffl, Law Section 420 1(7);
10. A chief fiscal officer ofu county ora Public admini^traimappom1edpursuant to the Sunogube'o Court Procedure Aut�
10a. Any other person who is acting on behalf of the deceased and wno has executed a written staternent pursuant to Public HeaIth
Law Sechon42O1(7),
fiaJALL �RBof the following)
C �J \ Me hereby affirm that the body of the deceased does not conlam a battaryr bat paok, power ceU. radioactive imp ant,
ot/�d\oacUvndnv\cpondtho|anynuchmatmno|awererernnveUpnorto1heexeuW,ono�th|oAu8hwrizatimmFmrm, Failure toremove
P
ems prior to cremation may,esu\t\nhonntothemrennatoryandcrwmmtorypormonna|.
Wile affirm Pm�r.ciuK0me/
Mn instruuionuhsvebeengivep1:nmg�eemcva|oYanypemonalproperlycr,nther thing ofvu|wewhich any person signing below or any family member of the
Pine View Crematory
deceased wishes mpreserve. __ - ... ...... ...--... .... ................. __ ..'......
is not responsible for the removal uf personal items from the uoma/nerm from theremainsof'he deceased. Personal items left in the
container with the remains will be destroyed by the cremation process and cannot be retrieved mfte,sremo*ien.
. �»iOe \/ieVV [|[GOO81O[V
>M�wher�bymu�hu�ize
to cremate the remains oYthe deceased.
I/we hereby authorize the named funeral director to provide for delivery to and cremation by an alternate
iydmenmmdnecwmweryintheopinimnofthefune,m|6irector.ondtoamwndth|wfonnoopnovidethe corrmntmammwaqd
®rematory,
mdd,ews of such alternate crematory.
FINAL DISPOSITION
The person authorized to receive the cremated rerxamsnf the deceased from the cromato,yis�
Brewer Funeral Home, Inc-
Name:
24Chorch St.. LaxeLvzrrnr, mv 12846 518'696-2744 ---
Address:__., Phone
_ _�___ ______-__-_'-____-__
The cremated remains m»deceased will»a disposed ofmafoUowo:
return tnJa,n�s
-__.____
K for any reason the person named above does not take possession ofthe cremated remains
Pine View Crematory
___ ������� __ ___ _ is authorized to give.pmmuesaio/,of
Brewer Funem/Home- Inc.
the remains oo
N"'.w) __ _�__� ____�________ _-__- by delivery
,n person o,Uy registered*`aii Ruth E. HODle8te8d
N^ ��
QOS-18SO-f(Rev.04,12O)
�
Auuxo«»viza«voxv for Cremation and Disposition . _
unde stand!hat �i lhe rernairss are no,cla�med within 20 days o"crerration.
p� *mry may dispose of the remains m
an /rret6leva�e manner, suchaobyscattering,
CREMATION, CONTA|NERt_UF�!
i,,/ /ONEofO`ofclxo'4411g)
An umtohe used asa container for the cremated remains haa been puroriasad from, ___- _-
�6nd'ndaucnomdashoUm«u:_�
|8Veuoderstanuthe,if!heumisk/osnna||tohoid\heenunec'emavedrernainm. anaddihmoa| nUidnonta'nermayheusedMordo|ive,y.
-0R-
An urn is nat yet Purchased. {0Vevndeatand that ifno urn is purchased o/other-wise P,owded
Will
place the cremated remains m
angld temporary container for delivery
Patricia Miller was executed w¢
This Authorization Fnnnwasp'ov'dedby —----- -�
Brewer Funeral Home, Inc.
-- ------
24Churc` St' Lake LuzemeNY 12846
and is signed by the tunera'director aswl,,nessuo its exeou*'on�
|Ve have received axooipjeted copy ofmio Authorization Form.
The meson(m)identified 6w)wxv io/a,ethe person(s)}n cmot,ni of disposition,who by signing this Authorization Fmrm,attest(s)
to the accuracy and completeness of the information contained in this Authorization Form and authorize(s)the foregoing.
26 Januory 21
Signed this day of ��___�� ���� _____-. 28
James Homestead
r����=�°*������� -- ------- �� ���------ - ----- ' - — -�- ��-------�-�\-�----'- -- -- -�
2O9 Dolores Terrace Sown, NorlbSy/acuue NYr321Z_____
�__
-- ----- --------�'------- m�x�����- ---- ------�---------- -----
es s
_-__
Patricia Miller
' =p=������� ------ -- -- ----- ����r��.�� �---�-x----------------'---
12465
RUth E. HODlestead
DOS'1898-f{Rev. rj4f2O) Page 3of3