Gillespie, RobertUF)
Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: _Tµ— RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: Thal Z3 to.l0ffn
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
lid _.Hopunq
NAME: - — R��_—IL—LS� CASE # Z
TYPE OF CONTAINER: 635f4r ld-,
PLACE OF DEATH: — 440T f4t ci' Y6Up rAL______
ESTIMATED WEIGHT OF REMAINS & CONTAINER
PLACED IN HOLD:
PLACED IN REFRIGERATION: f D: qc-
DATE OF CREMATION:
%11117
TIME STARTED: 11:00 7 l TIME COMPLETED:
PLACED IN RETORT: �� MOVED: _ �1;)6 p1T_��
RETORT # IN WHICH REMAINS WERE CREMATED: sv?(.K- 17o_Q PAK
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.
n'are the
-ciFt �ICSt +i1 en W r
s�
lVe have no k oLYI 4
willttaialn dieOnS t d#s�
I lealdl L aMr eaiion 47A1 �dls-p of
toV deceasedsls:aa„f andhav tt dghtto
Number 3 Description: Any surviYitl c
9 hitd eighteen yea%
2. The surviving spouse;
2a. The surviving domestid
3. Any child- partner -
surviving
4. A surviving parertt,
6. A lawfully aPpoi# r rt
nted�guar'd ri
7' 'Any das (s}eighteen yearaa an a
A.du�
A close friend or relative who has executed a H 10. A chief fiscal officer.of ax ounty csra ecu61 ,te ,,adY
Act
10a. Any other person who �s acting behalf of thf
Public Health Law 3qn�
aic
For numbers 3, 5 and 7, above,, by signing the poison s s`
majority of the members of this class of persons+lto sce :artl
i f8a�9F��
( 7i BOTH of
f�rllowing) a , �� �� � �
^— INVe hereby affirm that the body of tha ate aossodeio
or radioactive device and that any such rr}ateiiaIsVere, removetlr(or
to remove these items prior to"creertson►ay result ifti fm {o
I/we affirm that instructions have been given,to aft q
regarding the removal of any personal property or other thing pf value which apy
member of the deceased wishes to preserve;; „?ine.,View CreJM- ' ry
is not responsible for the removal of personal items frorKthe container irr frotn;the fe a personal
items left in the container or with the remains wilt be destroyed tsy%tha cremaio% `p
after cremation.
(Initial OPTIONAL)
Ime hereby authorize the named funeral director to provide for delivery a ��
crematory, if deemed necessary In the opinion of the funeral director, a>€t e
correct name and address of such alternate crematory.
Address
WITNESS:
Morgan Wicks
jFwww ombr Typed or PnnW Name)
14694
(Rop&mftn Number)
DOS- 1898-f (Rev. 06/23)