Ostrosky, Frank TOT�N OF QUEErA�5BU-r�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name Fra�n�C Cis +v5� Case#.
Date 0f Cremation se of- Z`6 700
Time Cremation Started '3 �M
Time Cremation Completed_ Io'
9 n ,
Type of Container C�+c
Remarks
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury,New York, 128M ,
Cemetery Office:(518)745-4476,Crematorium:(518)745-4477
Authorization to Cremate
The crdersigned requests and authorises pine View Cren dorium,in accordance with and subject bus Rules and Regulations to
cremate the ren uins of:
F)ZANk J' O5 ky Al
(Name) (sera
(sb") (City) (state) (gyp Code)
who died on "5rr"7—Z 3 —2e=-
at ;?J- 30 , 5s►r3F�►C l�.✓a..sw �.vJ �Jy
(Place) O
Name and address of nearest living relative or name of person authorizing aernalion:
j/-tx 601�I�S�'/EN J 7y� X 4.�r�Z?ti AvE� ,� L.l�a� AJY
( ) (Address)
Relatiorwhip to the deceased
Name of Funeral Home 1 VIV J=�
IMPORTANT: .tY,battery petit,power
I represent that to the best of my Ivwwladge,the deceased(tray)or(hes no)pacemaker:
cep,radioactive rrnplant or radkxx*a device in his or her body.((Ads One)
I certaY that I have M power and au0rorlmdon to arrange for the aematbn of the remains and to direct the disposition of the
cremated remains.that any personal possessions have sonar been removed ar may be destroyed,and agree to protect,defend and
save harmless pine VlVw UremabrMxn horn any and as claim and demands for loss or damages which may be made 89WW them
by reason of or cogrAKIed with the awnetion d said rernSIM as directed,whether such damns or denrerds are or are not wtmAy
groundless,
(Address)
pograture anti
of Relative or t VW Representative)
Signed on this date: IFG 7
Disposition of Cremated Remains
I hereby direct Pine Viaw Cremebrlm to dispose Of the cremated remekrs as follows:
Mail to
Other arrangements-Please spedfy:
if pulverization of cremated remains is requested,che*here
Revision:Apra 18,2007