Gorham, Carol E ( i r
Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: _ $K
-- RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: __— GI 113 J 13 7;34I�
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
NAME: _.__._.._....- C� �- �O I_611_..-- CASE # 13
TYPE OF CONTAINER: h00141E0 (6PMt - rkik,00til2n
PLACE OF DEATH: MCpudit_CrD uliAlLk-2_ - MSTC fich j�
— AoTftakkp
ESTIMATED WEIGHT OF REMAINS 8 CONTAINER I / 11 ids
PLACED IN HOLD: pri
PLACED IN REFRIGERATION:
DATE OF CREMATION: 11 S I 1))
TIME STARTED: �_20 TIME COMPLETED: I'
Lirrth
PLACED IN RETORT: 1'LID Ati MOVED: q:25 ' 9:00 ill i Tio
RETORT # IN WHICH REMAINS WERE CREMATED: S '''I
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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Atalt0 • for Creerrettori and Dtsposittort
tifft*0140140441014.014 rt141,14 Ok-CAIA tmt#.-t, 14$0404140 a#441stgeod pett4 404,04t0 44''0,"05%%tot ors%"0,904%'
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9112/23
Date, Notrit,uf . 11,3 jf-E,y1
Pete littee ClevOtketocy
CAtrttbttt'y Kerr*
CttheitArff rtberr Otitebtlebitry NY 12608 .ft,7firt.8279
iitiodress
CtilteniATION As AISO FINL..PROCSS.
Clrereweyon berbttO erig by pkbeirPO the remains Or the deceased and the net hoid.mg the ernaont into cvernalion aterriber*hetet
"*44.6/16144 #41tatiVe tlehid irrX1 frame. The hest end flame will incinerate end consume everything except boil*end metal:
*Idea Am en that ea,tes teft iNftsOr ChtfrrOtiOrt,
1 a. '411140 P"ermiloon oramaittey will take reasonable efforts to remove all of the remains and other matenal from the cremation
htFtwriettit,Put same ebritkrtli dust and ntructue will likely be left behind. The aernatory will separate incidental and forelgri material from `I
rhe fernaertS and Ole intbelentat sind foreign rhatertat, including dental work and implants,will be disposed of as permitted by law. The 1
1 oreatat, reirbSerte We be mechanics*pulverized into small pieces and placed into a designated container Of urn, Cremated remains
1 eft pridlietiZad untO he single fragment is recognIzable as skeletal tissue.
EQ
Cam!E.Gorham Widow
Name Or Deceased: Marital Status
Last 6 Rudley Dr Gueensbury,NY 12804
,Known Address
NY
Place of Death:Municipality:QueEinsburYState
Gender El fit LEI fjj x Age: DO8 1215/1943
Date of Death-9/12/23
Estimated Weight 14°
The crematory may only open the container holding the un-cremated human remains in limited circumstances,such as to confirm the
identity of the discessed or to ensure that no material is enclosed which might injure employees or damage the crematory property. If
human retrains are delivered In a container Mich is not suitable for cremation such as ceremonial or rental casket,the crematory will
require that the remains be moved into a suitable container before it accepts the remains.The opening of a container or the transfer or
removal of remains win be conducted before a witness and will be done in privacy,with dignity and respect
DESCRAPTION OF CONTAINERN VIICH REMAINS AIM BEING DELIVERED
McDonald Container Cardboard
Manufacturer or supplier Material:
(initiAf ONE of Me AY/owing)
\(77.(L Pine View Crematory
'Me have provided with an urn to be used as a container for the
iliattro&Dame/boy,
cremated remains. Me understand that if the um is too small to hold the entire cremated remains,an additional rigid
Custom Wood Urn
container may be used for delivery. Desaiotiori of urn:
tAAfe have not provided an urn to be used as a container for the cremated remains, and understand that
Rifle View Crematory IMO place the cremated remit*in
ovarm,
a rigid container for delivery.
6 ,
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•':!!.;?. gte.:4;44..Sr4q411,*41"T"'iL ,
1tt
TMw .. RatetliWts eite the itattaristed iikaeatt daa disaicesed designatedar,a will tit aantten instrument 9 .„1itr ti pursuant tca Pubtic
NoWiti Law Seek*
Ave Noe
a Written inaturrient pursuant to
c Health Law
. itantatteartg a rieuitedo,e that the deceased€ r d of his o he ten-tams rvs and lee*are theperson(o)having�srnonty under��ic�
Wealth Law Seam 1 and nave the right to authorize cxemaatbon of the remains of tie deceased tfAyfOur retattonship
Number3 son
Description_,
2. The s€r +r'diirag spouse,
. The sunnieing domestic partner,
3. Any surviving child eighteen years of age or older,
4. A outlaying patent
Si A Straying sibling eighteen years of age or older;
lawfuey appointed guardian.
1. My (s)eighteen years of age or older entitled to share in the estate and who ist'are closest in relationship to
the ;
. A duly appointed fiduciary of the estate
p, A dose friend or relative who has executed a Bitten statement pursuant to Public Health Law Section 4201(7),
le. A of acounty or a public administrator appointed pursuant to the Surrogates Court Procedure
A
10a. My Other person who is acting on behalf of the deceased and who has exe. ,ated a viritten statement pursuant to
Public Health Law Section 4201(7),
For numbers 7 above,by signing,the person(s)signing this Authorization Frain represent that they are signing on behalf of a
majority of the members of this ass of persons who are reasonably available.
g Boni ofthe )
INVe hereby aft that the body of the deceased does not contain a battery, battery pack.,power cell,radioactive implant
or radioactive device and that any such materials were removed prior to the execution of this Authorbation Form. FARM
to remove prior to cremation may result in harm to the crematory and crematory personnel
l affirm that insbuctions have been given to Michael Miller ...w
fit r
regiwiting the removal of any personal property or other thing of value which any person signing below or any family
member to preserve.
Pine View Crematory
t Crory decor?
is not responsible for the removal of personal items from the container or from the remains of the deceased. Personal
items left to the container the ns will be destroyed by the cremation process and cannot be retrieved
I 1 N-
hereby -a : , . the namod funeral director to provide far dotivery to andr,; by an, r .. r...
t«, rN In the opinionoft funeral& r and to form to provided*
correct nom and e of such alternate
Caroi E. Gorham
Mavis or
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. '...• .k a( i; .Y. n and Disposition
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. aolkato o t 4 rna d foolarka eo tt tee,eased
a t
��e� a� ° t t ryCemetery, iiiirttt tii rea 'airs
w m tea,
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r# to moot,*to.ioLottt.tot$,o,"•spk0 t.i„t $t„.41a :.. 14C:w t to..esirr stery is
w +*�
J leeitit atationse ate fumes director evecirang this 3 utheiti$$Wi r5 t.corn,wee name spurs 0419 page3 of this hem
to reseriiisi
a r his to het t€rnerr$i firm to remise ise the cremated t remains on rrty1OUt tishail
if'kir ' t acres not take possession of the exerneted remeinti,
Pins View Cismatory is sty ll:siz t to give possession
Etrewor Funeral Home, Inc, � �_
t t —�,. ..._ ,.:. .�
r Lela-ad States Postal Service, as permitted by de regulations and p lures_
tssatistand tttat itthe remains are not ddirnerd within 120 days of aramstiOrs,
Pine View Crematory
.._ _..,:�. f ...
,� . rvo r.Crr toy.
of the rent-sins in art irretrtevaattle manner, as permitted by law.
tiittictleat Miller
Thin Authorization FOITII ray provided by _ �..�
Home, was executed at
Brewer Ftinerai Inc. wm o ...
4(;htirCh SL Lake Lumina,NY 1 . .vv
ire. w.wa.
'. . .. ,...,®...,_W.:.:... � a..,. iFe@n�l�i�'dyrt't#�&is€oP�:SSJ
and is signed by the n director as ttriess to its execution.
i3We have received a completed copy of this Authorization Form.
in �$ciiai3 aerie by signing this Auth ti0n Form,atlases)s to e of
. ...,. a. nd
IN*ainfareth° thetrrf contained in this A►uthorizatittn FOarn and herby to ( tocremate
12 day et September 2fi
� 23
a rd
Michael Gorham
PO Box 247, e d NY1
mows '
zw4r w
Carpi E.