Richards, Jeremy Y Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: 0517e_r RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: -5-117A /0-e-2v2-z_
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
Cg 53 ,
NAME: _ . 17e5:e C ev-ct CASE
TYPE OF CONTAINER: G r rt &4j Ce-cf`CI be)41ct 1.3X Pl/
1-Pytito_cl Ai odd 3 gia,
PLACE OF DEATH: 77 74/4-tt..) 4 ..s 13, (e 44-14/ k 9:±74/
)
ESTIMATED WEIGHT OF REMAINS & CONTAINER 67? )0 gq,
PLACED IN IN HOLD: I
PLACED IN REFRIGERATION:
DATE OF CREMATION:
TIME STARTED: /00.44---- TIME COMPLETED: I Tr--
, 7_1,1?" I
PLACED IN RETORT: 105t- MOVED: lip- /
RETORT # IN WHICH REMAINS WERE CREMATED: 6_ti ". p_ai/de-r-
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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I V16p17.11 V.1010144W 9t4D
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Authorization for Cremation and Disposition
This AutherizotIoa Formfmuot be complomd and signed prior to delivery of remains for cremation.
( rllumlxu.
C•ernatory Name:Ptft5vmu Cr*nnrrry
Address:Quaker Road.Queatsbury.New York 1280a �— Phone-(5t8)T45.4477
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Crenmlon Is cameo out by placing the imams of the deceased and the c namer holding we remains into s amebae'chamber where
they aro subjotxed to intense heat end flame. The heat end flame wig incinerate and consume everything except berm and metal,
which are all that will be left after cremation.
FoT0wIng atxrteticn,the orcmata:y will take reasonable efforts to remove all of the remains and other material from the oremabon
(ttaiibrt:but some numeral dust are reshdue we likely be tell bthind T he tre iatary mil seaara1e incidental and foreign materal horn
the re ie and the inti3d>bl aid toregn material will be disposed of as required by taw. The cremated remains v ll be mechanically
puiverzed Alto small pieces and placed into a deegnaed container or um. Cremated remains generally are pulverized until no
single fragment is recognizable as skeletal tissue_
OPENING OF THE CONTAINER
The aentatery may only open the ebrealner holding the un.cremaled human remains In I1m-ted cirwmstenoaa.such as to confirm the
identity's!the deceased or to ensure thin re national is enclosed which aright injure employees or damage the crematory property. if human remains aro delivered in a container which is not suitable for cremation such as ceremonial or rental casket,the
crematory wig require that the remains be moved into a suitable container betort it accepts the remains. The opening of a
container or the transfer or removal of remains will be conducted before a witness and Witt be done in lnvacy.with a gndy and respect.
IDENTIFICATION OF DECEASED
Name of Deceased: �,,�(Q,ry‘.ti_ f RIeA.A.1^Gt5 tvtaritat Status
Last Known Address: /t)'(N 9 / c2 E2 iir r P-e. C.oA Jim Aft( 7 9/3 Y
Place of Death. jc+/ .5P Le. A aJ rsflC_
Sec �'M 0: Age. 417 DOB: i/2 S j'i S Dale of Death C� /5-A02'1-*- 1�•
Estimated Weight. O
Description of casket'coniainer in whion remains will be delivered
Corrugated Cardboard Box with Plywood Starmark Model#38808
PERSON IN CONTROL OF DISPOSi1ION
IParsonIs)mcosh&orders:ra onn.ki40IclAsE claw Wowing/
enUSW are the leslgnated agent ct the deceased designated in a will or written instrument executed pursuant to Public
Heaeh Lair Socron 420t.
L'` IAN&have re Arledge that he deemed exec:Wed a ariten instrument pursuant to Public Health Levi Sethen 4201 or a
wet containing directions Ior the dispcsrbcn of his or her remains and leas are the person(s)havng priority under Public health Law
Section 4201 and have t e right to authorize cremation of the remains of the deceased. fdy/Our relationship to the deceased is as
follows: p / y /U R f_'/C
/
DOS 189E f(Rev 04t20) Pegs tat 3
Authorization for Cremation and Disposition
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(tn tart tenon the 1st Weal r ,,
Number: £ Description. i •P+ /- (t,t O ALA.- S14-tAll n
! A person designated in wrifrng purs,rart to Pji.t Health Lae Section 4201(3):
2. The surviving spouse;
2a. he surviving domestic partner.
3. Any swerving at oighteer yeas of aye or older.
env . pare
A surviving erecgrreun years of age or older.
G. A lawfully eprrrnited guaretran_
7. Any person(s)eighteen years of age or under tainted to sham in the estate grad►vto lotto closest In relationship to the deemed;
8. A duly awarded fiduciary of the estate;
9. A dose friend or relative who has executed a veleen statement pursuant to Public Heath Law Scctron 4201(7)
10. A Beef fiscal oftoar eta county a a public odminlrtrata appointed pursuant 10 the Surrosale's Cowl Procedure Ant
10e. Any other person who is acting on butratf of Its deceased and who hos executed a written statemenn pursuant to Putklc Health
tam Section 4201(7).
(Indel ALL THREE a►the fuJonvr y)
0We hereby affirn-thsl the body of the deceased dote not Conlon a battery.battery peck,power des.rescoecnee implant,
or radroadive devrae and that any such mstoriers were removal prior to the exeekrtlon of this Authorization Form Failure to remove
these items prior to cremedon may result in herrn to the crematory and crematory personnel.
,e !Me affirm that rtstructie have been given to a sty igia190
,
ww.n:•sr.•ra.u�..ay
regarding the removal of any personal property or other thing of video which any person signing betas or any family member of the
deceased wishes to preserve Fine View Crematory
is not responsible for the remover of personal gems from the ex>tiluiner or from the remains of the deceased. Poreonat Rome left in the
container or with the remains will be destroyed by the cremation procmo and cannot be retrieved attar cremation.
Psi mu hereby aufhor)ze Pule View Crematory
r.+ean.rra"..
to cremate the remains of the deceased.
(InkMa//�0 ,F70At lL)
1 U�( Uwe herby authorise the,named funeral director to provide for delivery to and cremation by an alternate
crematory,if deemed necessary in the opinion of the funeral director.and to amend this form to provide the correct name and
address of such alternate crematory.
FINAL DISPOSITION
The person authorized to receive the cremated remains of the deceased frem the crematory is•
MoyneBaker Funeral Home Personnel
•
Addrasw 11 Lafayette Skeet.Cocensbury.Now York t2804 pelore. (518)781.93p3 i
The cremated remains of deceased will be disposed of as follows. --
.4eat saasrauttabe -Iu _$1Srei-AnP �rrt✓rt� _ _ i
qb q h1l)-t1-foil&- Cr. b frto S�r„� .i .g.t.1 SyL rib/-316S
i
if for any reason the perscn named above does not take possession of the aemaled remains
P ne Weyer Crwnulcry is authored to ghee possession of
itssereep uses
true remains to _-- Baker Funeral Home -_-- by delivery
in meson or by registered mail. /j �d�i
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s,an..ne
D3S•1803.E(Rev.04f20) Pogo 2 at 3
•
Authorization for Cremation and Disposition
7 �r.,o/ awvt•rg)
_✓. •!We understa^d that itthe(emars are not ctsimed wthh►120 days of aerfwbon,
Pine thew C•e•natory
may dispose of the remains n
an irretrievable manner,=it as by con taring
CREMATION CONTARIERriuRN
ihnatfaf ONE of the 1ba isty g)
Ar urn to be i.sed as a container for the cringed remains has bean p:rctrssed Gum Reiter Foists)]I'cmc
and Is Cestrrbed as Meths
IIWe understand rot If UTc urn is too and to nold the antra cremated remars,an additional rigid c nta:^er may be loud for derwery.
-OR•
,XAr urn is you yet purchased UWa understand that if no urn is purchased a Wei Lwiwio wwhfea
Pilo Mow Crompton/ win plea,the cremated remains n
sir,.JO.m etro
a ngd Mahoney ursiai o fur dufivuty.
sty
i his Authorization Form was pravided by t'.rsta A"f Auld() was oxecutod at
r eknta,.mn
Baker Ft,neral Home
rassomow aim)
II Lafayette Street.Oveitinseury.How Yerk'280.
�FIM.ab/MAK.•SSI.
and is signed by the tuner,)dtrecter as witness to its executcn.
twa tr<n%received a afnrlreed oopy of this Authorization Form.
The person(s)Identified below Ware the pennant*?In control of dispoeidon,who by signing this Authorization Form,awst's}
to the sccu:aey andcontpkriano of the information contained in this Authorization Form and authorizes)the toragotng.
Signed this I( day of s • .20 z Y
rp o a Rawl Maw 3.71RIw
A logy A4A-/4-9ofi - C 1 Cb1r e-40 'I" yi rsei �O ��`/a-5F
tract v Maw►me --- -. .:train
Adam
mood Sr4terSh4.-.r by.en C
A2Im
WITNESS:
Cassia Rafferty CA
2143.1 —94() LI*4'
raw rtJN v hAJ'An.* i
Funeral Home Rep.001130
a4a¢.tldd.r.aeJar. -
leiv=zi• �t644.rds
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