Doty, Barbara Ferne Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: IAIZtiETO RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: I hi 7Z [0;6411--
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
6 A(I t_ fAmR
NAME: _ BhfitiA_r_A _gar, CASE # g
TYPE OF CONTAINER: p1,444- „ A") el-. ,tort_ „0.2( ki-ah,
PLACE OF DEATH: Br#4-c(4-10 fair Ed,/ad 1?-z1 ( sas
ESTIMATED WEIGHT OF REMAINS & CONTAINER
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION: 61/ill 1/
TIME STARTED: ,/ofn TIME COMPLETED: Z;SOrl
PLACED IN RETORT: ). ls-- j11 MOVED: 2 )1L) ft2
RETORT # IN WHICH REMAINS WERE CREMATED: -rw4.._a_
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.
Department of
NEW YORK Division ofCommerce.� $
STATE.OF c1rs
OPPORTUNITY +cemeteries arny r� �any,NY 000
Te ephone:(51E9 474-6226
www.dos.nY. ov
Authorization for Cremation and Disposition
This Authorization Form must bs complstsd and ;h to d.lhrery of remains for crarnsition..
l 2i - i ?fig
Grerra t Name:!&ro Vie* to rittrra
Quaker Rd.,t utt nsb %10 t Phone: 518 745 4+1TT
1104 CREMAI AN IRREVERSIBLE'Al0F114/11.Ma &
t rerunstior oerried out i� renteiute of tl a deoented,l i -txxWter nofciing 1 remains ktio s�«ssmtio►►ammi e
they e , k i • �and cons me everythingupc+ceprt bone end nr+w,
Fallovrkrg aremtuation.the whh� re traMtie sfhb ha 07 of the remains and other material from the cremation
dlarttbe+r�but roes ml r alir reel vuwik-be The cxetlra ' vat separate incidental and for+ a material from
the remains and the irre ��m by#pet iThe mams ginissft remainspulverised
�
puorieed h armed pls ea,�pl iini a o t i?�Itadrqu r�hl ens pulwriasd until no
riTCOOstigibiR
They oon , circus lisbn4 . r aS to COrpert the
lilettt kite'tl d1t[It►arra�ueitltt a the crenattory D� M
ia�sadists at►thIpm ed ira i h as+pt erneniat ar rerubtl caslca ,the
- �+Nn� l��c�ortpb�flwr rnm�rirn. 'Frei operdng of a
rxtr��ur ttae ti ur a � wits be. done in privacy*with dignity and rasped.
s
t�N�ilrrxil�i.tlC• � � , '
��il dL�l_gedeo t* ,1 , " 1S (,±Pk ,�`�t�' ". ,r S MaritalStatus:Divorced
s
t �y�
� Estimated Wei0ht /`lSlbs
i ewx d e tlpti ett in Which reMeint be
ft Cremation , SI"iY boar °' ��w■q gory
! C * ems"
P Rkb ,M1 P � 6
v. +r. �` ut. .: 2 P2�'s�a a Yd tt� h � 3" u�5. ":
" I r
h arNWt are the designated agent of the deceased el ;in a Will of written instrument executed pursuant to Public
taw Section 4201.
Par-o* • NWe have no knowledge that the deceased executed a wrlttett instrument pursuant to Public Health Law Section 4201 or a
w+iM cordrdr imp ire ctlons for the disposition of his or her remains and Woe are the persons)having priority under Public Health Law
Section-420t and have the right to aufhodze cremation of the remains of the decreased. My/'Our relationship to the deceased is as
Barbara Feme Doty
farm of Ikatasfte
DOS-1898-f(Rev.0 0)
Page 1 of 3
Authorization for Cremation a # l s1UO ,
(Insei hem the list below)
Number Oft - cousin
t. A person designated w to Itl, putetra t to Pubic Maalgt Law Section 42°1(3);
2. The,sufviv�"ing spouse: -
2a. The suruiv!Uii domestic e'
3. Any sum eighteen�of aides d
4 ._A surviving i tYdi
Asurviving ors4-a oro_ , -_
',-A,layvfer ai � n
7 Y p � 1 ifs litr ► t who iet�lre closest in nsker�to the deceased;
>� '
ll. tee 1 _ 'Pc t:ewSecdcn4201(7);
IL ` � ° Les "' the SUrro e's Court procedure-Act
. ttfe llrgr t 'Ili* idlattlMrlerlt EM6bstl lk to Public Health
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- § .!1' ,4341 MM
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it �i�l
�9Ga S. . - priR�OMa0f1 IIiAMMId- » $ % { i_ , eS
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The R te0110 ed mmalns d l w�l be dI ed to'owe k
Ili
bi � I n doe.notm a i ct s• . lt rea�ir ,
R , � M�� _
� is to give possession of, ��414� _-
` by delivery,
�;' 4ems , fr• ► - Page 2 of 3