Symonds, Rocky J t
Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: MS Kt( #4 Q RETURN TIME: AMA-
DATE & TIME REMAINS ARRIVED AT CREMATORY: I I/O 13 2:41016r
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
kctr€ MckeESt
NAME: ROCICLi Z i Sy rtp4PS CASE #
TYPE OF CONTAINER: F1OCE ' (1' i - (U. f1.6 7CA,pp,l
PLACE OF DEATH: `17 LJ 5 "t" , f3 af.c }5((S J 4 (78U I
ESTIMATED WEIGHT OF REMAINS & CONTAINER 15-0 / ?io ( S;_i""4
_
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION: I /II I I3
TIME STARTED: /0 0S' Ar TIME COMPLETED: 17 :/0 f 7
PLACED IN RETORT: /D:Str MOVED: 10:Ts' /I : ?ti b I1 1Z_-to fh
RETORT# IN WHICH REMAINS WERE CREMATED: So 4,.-�IA( .
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.
t x y=
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tvr wiled -fig
n for Cremation and Disposition ,..,_ -
k ' ' ill rdat1on Form must be completed and signed p�rto delivery of remains for cremation.
,��t . �. , Number.
trA-rsk}. ,
- t = `Pine View Crematory
r Read.Queensbury,NY 12804 Phone: 518-745-4477
•-•'-'7-,-'=„1110t1 IS AN IRREVERSIBLE AND FINAL PROCESS.
le carried out by placing the remains of the deceased and the container holding the remains into a cremation chamber where
they ere subjected to intense heat and flame. The heat and flame will incinerate and consume everything except bone and metal,
t t :1afftaffper cremation.
.t .n • > .the trematory will take reasonable efforts to remove all of the remains and other material from the oret'rreon
•, foreign material from
� 1bAdt�tlrrle rrlininiel dust and residue will likelybe left behind. The crematorywill separate incidental and
f atria the incidental and foreign material will be disposed of as required by law. The cremated remains will be mechanically
!lib small pieces and placed into a designated container or urn. Cremated remains generally are pulverized until no
f einent is recognizable as skeletal tissue.
•�3 OF THE CONTAINER
.'crematory may only open the container holding the un-cremated human remains in limited circumstances,such as to confirm the
enIAr of the deceased or to ensure that no material is enclosed which might injure employees or damage the crematory property. If
'�x» are delivered in a container which is not suitable for cremation such as ceremonial or rental casket,the
require that the remains be moved into a Suitable container before it.accepts the remains. The opening of a
.or the transfer or removal of remains will be conducted before a witness and will be done in privacy,with dignity and respect.
RDECEASED
J.Symonds Marital Status: Never Married r
;�, ,,, is
= Street,Apt B,Glens Falls,NY 12i301
W
,„� �:{)$/23/1 992 Date of Death:01/01'2023 Estimated Weight: 1
50
fn-wltiiht remains will be deBvared;
. ..`•• _ , , ke t-Florence Casket Co. Pine/Cardboard
■ * 34 a i y• ,, Imo .. V/W.4-;
Si •
a will or written blstntment exect�d to Publ
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Statement pursuant -Public „ court procedure ,, v,,,,,„,. 30,,.
*.(L•3' 'Iffifitik it-lelefihvi who Ms executed a written , _ t to the Surrogates
':''..'' '''''''''''Y'•—"'----''igtfilitief '- or ti•Pahlte administrator appointed pursuant
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otte.- ,its countysog oft behalf of the deceased"MI Whbtitie-.0irecat.executed a
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: 10We' hereby*fern that the body of the deceased does not contain a battery,battery pack,power cell,radioactive Implart
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. .„- -
--::;.• ;.x -.,', .;,;-.---',,--;-:,11, :•.-- - .- -_,-•--
Stephanie A. Gilman
(Fitness,Director Name)
titleOthmt_.that instructions have been given to
liitAlliffitit14- ''' 'thiliteiriovai of sot personal property or other thing of value which any person ._
signing below or any family member of the, .,,,,, ,:,,, .-•
_ - '• ''- Pine View Crematory
&-..4k46:':'- ----., --,-..-114$1*18-10-11,961._ ,va-: - -' • (c„,,natoomame)
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'',',:'0%;,,';'•.:7;-'0"''''A''''''''''-.•,:'''''' '.,;'., lartheriaMaVai•of personal items from the container or from the remains of the deceased. Personal items left In the
.:,.-:(.•:.,:,.,,A44.,,,,,k%•*,i,'4:-- •'--'•'-'' ' " SteritiitiervAlt be destroyed by the cremation
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process and cannot be retrieved after cremation
Pine Mew Crematory,' _
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(CrematinNan* to orange the remains of the IA----"P"-...„-_--,--,.-., ....:,_.7--Atl'i.:`-i'iit-•;::A
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'----:•4. 74.s'''.44‘'''':.--1-.:;'2.;;;'''''''''''''' ''''''4''''''"-'• IliMedltintblii.director to - amend this form to provide:ther-.0-011", 7,77.17.k.-_---,::::::::--.:,?,•, •.'!,•';:•?.
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a� r e 3 forCremation and DIspo -''' - -.
t 4' 0041,411detttand that if the remains are not Chimed within 120 days of cremation,
I�M»ortAwne4liry) •• Y 1
manner,such as by acat#enng. �#;,,_
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r' ' M um to be used as a container for the cremated remains has been purchased from ,
.i1 _; i<t that if the urn is too small to hold the entire cremated remains,an additional rigid container may be used for dam`
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,..`, Y Pam. WGe understand t if-no UM—1 •Futtased-or otherwise Prsav - — rent-ns tit .; 4
' -,a,,, .,.. will place the cremated
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'�� ovary container for delivery. was executed at
won Form was provided by
Stephanie A.Gilman
�'` (woerai Dimctor Name)
Funeral lionlion.*oe
" * ?". - (Room/Home Name)
�4' ` oadway.Fort. d,NY 12828
r. r (Fv Home Addwrs) ,
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a `by the.1ditsd as witness to its eXecuttdn.
`• ` ' ,received a completed copy of this Authorization Form.
' below
i$lare the person(s)In control of disposition,who by signing this Authorization Fares,altest(s}
ilidiiiitinell
of the information contained in this Authorization Form and authorize(s)the foregoing: -'
` January 20 Ciiitliii:23
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