Kubricky, LeRoy (-rO q4N OF QUEEVBU9�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director � r-i2
Name J I ��� �� Case # SS��
Date of Cremation
Time Cremation Started v
Time Cremation Completed 3 2v
Type of Container _ ti-� [�a4 CA L./ rj f�fJ ' 6
�I
Remarks :
• �� v�6 z-coo
Z- 2(SA
Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury,New York, 12804 ,
Cemetery office:(518)745-4476,Crematorium: (518)745-4477
Authorization to Cremate
The undersigned requests and authorizes Pine View Crematorium,in accordance with and subject to Its Rules and Regulations to
cremate the remains of
LeRoy "Duke" Kubricky Male
(Name) (SOX)
11 Garrison Road ,. O(Cnye)ii "ti '"" T�Tnc.� ynrk 1(State) (2R�4
(Street) `7 �1 uP )
who died on �� of t'J eC�m
(per) (Address)
Name and add esB9,nearest riving re"e or tame of person V ae n0m:
L� 11 Garrison Road Queensbury., New York 12804
r 1CKY (Address)
RetationshiP to the deceased Self
Name of Funeral Home M a n a r d D. Baker Funeral Home
IMPORTANT: s no)pacemaker,defibrillator,
battery,battery pack•Power
I represent that to the best of ttry Wowledge,the deceased( )or or(has
One)
,
cell,radioactive Implant or radioactive device in his or her body.
I certify that 1 have ful power and aut wtwdonr b arrange for the aemetion of the remains and to direct the disposition o defend f the
and
remains,that any personnel possessions trove either been reproved or may be deocyed,and agree Protect,
save harmless Pine View Crematorium from any and all claims and demands for loss or damages which may be made against them
by of or!( 7
ected with the cremation of said replants as din cbA whether Such r l el or demands moor are not Wholly
11 Lafayette Street , Queensbury, New York 12804
ubrick
Signature and of R or Legs'Represerrtatfve)
Signed on this date: J a n u a r 8 2 0 0 8
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the Cremated remains 89 follows:
Map to
other arrangemara_pleesa Wecify: To be picked up by Maynard D. Baker Funeral Home
If pulverization of cremated remains is requested,dxKk here X
Revision:April 18,2007