McGuenness, Barbara Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME:
RETURN TIME:
DATE & TIME REMAINS ARRIVED AT :
CREMATORY•
OW
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING
;�
REMAINS:
NAME: ----- —
CASE # Li0g
TYPE OF CONTAINER:
51-7`tkin42( C R�Bo RD-___PSI
38gag
PLACE OF DEATH: L vRN
Ott 6)5eo
ESTIMATED WEIGHT OF REMAINS & CONTAINER
PLACED IN HOLD: z���r
PLACED IN REFRIGERATION:
DATE OF CREMATION:
TIME STARTED•• `]=
TIME COMPLETED:
PLACED IN RETORT: _ 1't8
MOVED: _---_�.�'SS'1�►"J1 ,,(}�
RETORT# IN WHICH REMAINS WERE CREMATED:
Su?
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48
FROM TIME OF ACCEPTED DELIVERY: HOURS
NOTE:THE CREMATION LOG SHALL BE RETAINED IN THE PERMANENT FILE OF TH
E CREMATORY,
ri
New rock cute
NEWYORK Division of Dep'�1N1of State
STATE OF DIVISION OF CEMETERIES
on avenue
°""U"I Cemeteries 99W Commerce Roza
Agony.NY 122314001
?et.ohonc Ise!)Q46226
Authorization for Cremation and Disposition wwweoair•ov
This Authorisation Form must be completed and signed prior to delivery of romans for enmatlon.
Date: 5-1(9 1 1-3Case Number(for crematory use only): L/0R
Crematory Name; Pine View Crematory
Address: Quaker Road,Queensbury,New York 12804
p)gra: (518)7454477
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation Is IS AN out by plating the remains of the deCESS. and the container holding the remake we
s cremation chamber where
they err sub)ected to Intense heat and name. The heat and Mm•will Incinerate and consume everything except bone and metal.which are alt that wit be left after cremation.
Follow ng cremation,the crematory will take reasonable mores to remove al
of t e remains and other meterW horn the,erimsllsn clamber,but some minima dust end residue wig lkey be kilt behind. The crematory wig separate incidental and brags u law. l porn,
Cremated remthe remains ains the I be ntalmec asnd f Mom,is dental work and knpkiMs,wig be disposai of as permitted by,hw. The
N putwr@ed Info anal pieces end plead ki o a designated container ovum, Cremated remains r
generally are pulverized until no single fragment Is recognizable es skeletal Nssue.
OPENNtli OF THE CONTAINER
The crematory may only open the container holding the ten•enmated human remains in waled draerntancsg such as to coi*m the;
Identity of the dece•see or to ensure that no material Is enclosed which might kn)exe employes or dams"the crematory properly. M human remain ere delivered Ina container which le not suitable for cremation such as oanmonlel er rental casket.the
crematory will require that the remains be moved Into a suitable container before N sooepts the remains.=The.open ng d a container or the trans*r or removal of remakes will be Conducted before a witness and wig be done In pMsey,with dignity and respect. ;:
WENTIFICATION OF DECEASED
Name of Deceased: Y1f'r� N(G�teflil � M•rlteiStabn j)1[tl[ AtOr
Lan wwwn Address:30 Rcekl
cl►rl.Ftutpt it ,t eg:PCIT Q�` i"R41J
Oeeth: .„�- u ,,:"n r ;r`.9 `. x' ',t or,,,, i
Pleat of ...\t" .► Q.ra.. la, '�° 0,► " �i°A ,a r,t 1 �� ��.` loam '; ;,,
Gender M®F®X Aga;Cl� DOB SI a ' � " ., £ #' 'r i -
Oescr ptlon of CaskM/oontainer le which remakes cote be delivered r 'tea �" I ,�'"
� �I�dr L i arc!''6 r 6 ado �. s ¢ r4 1,4, t e
)ERSON IN CONTROL OF " 4 ' '�°� {
(Pason fall in Condof o/dOF DISPOSITION
n, the . K gr .„ 't
Y
I ernWe are the dagnetdagent of Illfr ,.. �
Health Law section 4201 r.'� 1
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YWe lave no 1 ^r- c.7,, i r 'r%
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�1,.� 1 t i °' �n dr+ c 1 nti,
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- -----.---.. .—. _._..._.._........ .....r.,.,....,..
(Insert from the list below)
Number: Description:11A rj n l
1. A person designated in writing pursuant to Public Health Law Section 4201(3);
2. The surviving spouse;
2a. The surviving domestic partner;3. Any surviving child eighteen years of age or older.d. A surviving parent; xS. A surviving sibling eighteen years of age or older;IL A Iswtuiy eppolnled guardian; :4,,,,,;:ic-1:::",iitli,"
7. Any penwn(s)eighteen yasn of t
•. A duly appointed fld or older entitled to share In the estate end who Niers closest in relationship to the daoaaaed1. x ,
ueNry of the estate; , ;
0. A close friend or relative who has executed a written statement pursuant to Public Health Law Secllon,201(1X k
10. A thief fiscal el of a county or a public administrator appointedi' ^ `1a
10a. Any other parson who Is acting pursuant the S rrog te's Court Procedure Ad, x,, `` 1, ,`5
Law Section person
420I(7). on behalf of the deceased and who has executed a written statement pursuant to Pubic McMh ' �
For numbers 3.6 and 7 above.by clOM+O,the person(s)signing this Author nation Form represent thatan s ! fr ''majority of the members of this class of persons who are reasonably available. they on a 5
BOTH oJm.1o11owlnpJ _ fi
"/ Vide herby affirm that Me body of the deceased doss not contain a 4. 4 ->
UUor radioactiveby device and that any such se were ate'bey p� Vim►ce1.' , a °t ,
to remove thaw Items prior to such manremoved to the execution of INNon, , s
may insult In harm to the • fly
i IANe affirm that kMhuCYens have ),� ` "`"
been given to $ .1.•$ ► sell( ' 4.^-, , �; 3 '' v., ',a
regarding the removal of any "" r
personal property or other thing Ice which any elgnlnp below or an s . - W`
member of the deceased wishes to preserve
yfaat8y�
a g F o
:.`'!. Y Is net responsible for the removal of personal Qems from the ,1 �7'reeq' A r*r am.y.,,y t`r';,J k
=items left In the container or with theIrsy.d er or kiln
remains will a.dastreyad by the cremation a 4 j { Secs" y '":
- after left cremation.
�, t. „xr d a•a.. :4 4 �' .
•
to J > �,
, .�+�frer the named funeral director to provide for ANXt. ,1�`" '; a :`
>� � Seery overtire of tire lrreral d4role► +`"�
correct name and address of such akeneta.cn a rya.a + - '�" - "" '.1„ R�
r�x 4.,FINAL`DISPOSmof( - 'arn+*a `x.'✓� iY E t'"' a"e '��^
Thefinal mord Place for the cremated remains of the deceasedis { ,,. t. A, ,
To tie Detemlined ;, M . >
�s mayy:
{n`
, Nth*funeral director wfase signature appears.on page th ea t 1
tsIed remains of the deceased from Ma crema1�}"pE
1G•.
�' a` xv E pay'''•
!floe any reason the person named above*Steno(to �„, fi
h ,
tere airs
In parson a via Nlvery ¢(hllNd ° -
eg0f .01 z
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,,,,„,..AJz..,,,,,;,•,..41.4a;,...erVIVM,7( 3,1M1W,It. Al. 'i',,"'-'O4,t;.:'4;''-,,,'',.',,:;;..' -
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'' • Authorization for Cremation and Disposition
�3 z` me/oAo,WnO)
U e understand that If the remains ere not ctelrned wIthln 120 days of cremation.
Pine View Crematory
r+.w wGr�rM may dispose of the remains in %
an Imshievable manner.such as by scattering. _a
CREMATION CONTAINER/URN
!J►xEa/ONE o/Ma o#otw,g)
tNVe have provided Pine View Crematory ,tA �
es.�swor„ Mtn en urn to be used as a container for the cremated' ;, ,k "*" ,
remains.The urn is described as follows: s ,, }
UWe understand that If the urn Is too smal b hold the entire cremated remains,an additional rigid container may,,,,..,,,,,, " � '` *�
-OR- for dsRvery. ° r
�� as , s
awe haw not provided Pine View Crematory
en urn to be used as a container for ti►s txsmated remains,and understand that A� , ` , I° `
Mw el ivery. .p P�a9e the'rf g C s t i
a rigid temporary container for dalwry. p • f, r-
Ns Authorization Form was provided by Casale Rafreny A1�100 � :ti
affell art y w irk: s�4,, t'^`
° Baker Funeral Home ;,, � ' � rr���-
r+�...r,.w.w.,y L 4
11 l of. ells Street,Queensbu ,New York.12801' : i, ) ' ` r ,'; .-
and k signed by the ammo director as witness b Its exaw•mw 'k 4 �^
UYW hew reoalwd a completed t:opy of thisF
person• In ` , —
IIYVa Ware tin ( ! control of dteposltlen,who by�IpnNtO i �� � � " �� �� ��`
eamplalaness of the (s)I information oontahrad In lids " ,,
p3 oc
deceased. Autiterbrstlon f. n and µr. y
8lyntrd �Dm � x�s
thk day of Jf r
�`= � /�" ; ,, . +� a�;..: - _ _, _
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1'jrrMoM�r�w.r. ..' .r x3'4r �..� .. .
5.. 4 W.'
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WITNESS. z
Cassia Rafferty", _' �
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