Kaznowski, Gary (2) Pine View Cemetery & Crematorium
Quaker Road
Queensburyl NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: _ _ NaL RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: b lZI P40 i -iOPM
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
EFLSe4 Away
NAME: _ CREJ ICNT.I. wsm� p CASES 10
TYPE OF CONTAINER: / *dd AHWl P d In 3CE09
PLACE OF DEATH: 131 I`&'1 upFNNh9�RF µJ I1Pgr
ESTIMATED WEIGHT OF REMAINS & CONTAINER .3P 1jr
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION:
�I Wzj 170
rt
TIME STARTED: _ IZrd" TIME COMPLETED:
PLACED IN RETORT: 111011 MOVED: ZiBD(11 'LwfV
RETORT O IN WHICH REMAINS WERE CREMATED: _ _ Ci}$/_ $&A LbV
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SNALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
it
Authorization for Cremation and Disposition
Ore 4mmera neu.99 WNwzz`a
abed,NY MY
Mammon
nor ABMonaabn Fong must"corNplatM a signadpN M Mivary of roman rorcremaoon,
Date: Number. -70
Chalcedony Name: Pine Yew Cremai
Address: Contra Rued, Oumi sbury, New York 128D4 Phone: 51R174544TT
CREMATION IS AN IRREVERSIBLE AND FINAL. PROCESS.
Cremation is carried out by Placing the remains of the deceased and the container holding the remains into a
emoration amberwherethr subjected to intense heatand flame.The heat and Rome will lMna wale and me
m m
everything Dewittes ow and metal,which arc all and will be left after ate Wm.
Following cremation, Me crematory will take reasonable efforcs to rem che a nofthe remains and other material from the
cremation chamber, but some minimal dust and residue will likely he ad behinQ The crematory will separate incidental and
foreign material from the remains and the incidental and foreign material will be disposed of as required by law. The
cremated! remains will be mechanically pulverized Into small pieces and placed into a designated container or urn. Cram
mains gemralry,are pulverized until no dnges fragment Is femgnlzable as skeletal Souse.
OPENING OF CONTAINER
The crematory may only open the container holding the unKremated human remains in limited circumstances,such as to
confirm the memity,of the deceased or to ensure that no material is enclosed whim might injure employees or damage
story, property. N human remains are dWWa inacontainer whim is Axis callable far cremation such as a ceremonial or
carded casket,the vemalory will require IM the remains be rowed into a suitable container before It accepts the remoras.The
opening of a container or the transfer or removal of remains will be conducted before a witness and will be done In privacy,
with dignity and respect.
IDENTIFICATION OF DECEARED I,
Name of Deceased: l kj@-Z l tiK ( MCH1aI 51Btus: �IIJ
coat Known Address: is r\ Q tjovsti ¢va�r .Ut1 i�
Place of Death goer) ,
Sex: HM OF Aker noB jii Oataof Oaea: (A Estimeted4VelOM: ZM N-
Description of casket/container in which remains will be delivered:
Corrugated C dbo d Box with Plyworad5 kModel #3AROR
PERSON IN CONTROL OF DISPOSITION
(Person(s) in control ofdisposition, Initial ONE of the following)
I am/We are the designated agent of the deceased designated in a will or written instrument executed pursuant o Public
Health Law section 4201.
-OR-
/{ I/We have no knowledge that the deceased executed a written instrument pursuant to Public Health law section 4201 or
a W'll coMeining directions for the disposition of his or her remains and (Continued next page)
Nalaw.rane..mnm xxxxx��u li y,rat
' Iare/we are the personnsl having priority under Public Health law section 4201 and have the right to authorize cremation
of the remains of the deceased. NN/ourremWmhiPto the deceased is as Mims:
Yorco mm the list 6ebwl
Number'.2Nscriplron'. Af `I l
A person designated in will mursuand b Public HeraIM law smalion Q01 (0);
2 Thesurvlvingspouse;
2a.The surviving domestic partner.
3. Any survlNng phdd eighteen years of age or older
a A survvng parent
5. A surviving sihling egMeen years of We or older.
5. A lawfull ppa riled guall:
). Arty pereon(s) eig nyears M age or older husband to share in Me esHa and who share contest in
ante ;
m. A duly appointed fiduciary Mote estate,
9. A close Mhnd or Native who has executed a wrihan statement pursuant to Public Heash taw §4201m;
10. A chief fiscal officer cf a county add public atlministrMor appointed pursuantto the Surrogates Court
procedure Act,
IN. Any other person who a acting on ashes of the deceased and who has executed a written sHa[emeM pursuant
M public Hamill law§420101
OpjOwALL THREE of thefdbwagf
\(rl: I/We hereby affirm that the hotly of the deceased does not contain a battery, hattery pack, power cell, radioactive
implant,or radioctive device and that any such materials were removed prior to the execution athis Authorization Form.
Failure to remove Neu hems Prior to cremMlon may remit In harm to the Crematory and Eventual personnel.
IAve Mreby,affirm that Instructions have been giw:n to p...,ewee.rc..+mer regardingthe
1 removal of any personal property or other thing ofvalue which any person signing below or any family member ofthe deceased
wishes to preserve. rm m i Pine View Crematory is not responsible for removal of personal
items from the container or from the remains W the decel personal hems left In the small or with the usua lre will be
t esho-yl b e emot
ion prom worse answered
s and rse be wered alter cremation.
1-�"f l/Weherehyawlsorhelvemnnrvnome, p Ve Crematoy to consumers remains of
theaecesud.
FINAL o sPOSPHON
The person authorized to receive hu cremated remains of the deceasetl hom the Crenatory Is'.
Name. Baker Ful H P n
Axiduess I 1 Lafavelm Small Quidedligry, Near Y M 128M Phone: (5181161.a0KI
The wemMed remains of deceased will be disposed of as EDIIVxa'.
Rehm M family b be decried
If for any reared the person named above does not Hake possession of the cremated remains,
Im.+�nwrenal y' C is aMhor¢ed M give ppsseas of Me remeinsEd
pu+emimmeume maker Funeraltlome —by delivery in person or by registered mail.
l ��122.UOW SLl
oW,asHlxer.aaMl amml—w erRana
( Irmfe'kliawmel
11
I(Ae understand Mat d Me remains are M d in1M wiu,m 120 days of cremation
(wwreruv+eme) Pine View Crematory may dispare of the remains In an merrievaDk manner,
such as by scadedng.
CREMATION CONTAINERNRN
lNielolONC fdwhlbwinp)
_pn um to be used as a container for Me crenated remains has been purchased Inch Baker
Funeral Hanre and is Mandate! as selves'.
IMp understand that it the um is too small to hold Me there cremated retrains, an addtional rgid container may be tend
fordelivery.
dR
2�<—An um has not yet been purchased NNe understand Met d no um is purchased or othenaise provided twwnamr
namid Pine View Gremai will place the cremated remains in a Nd temporary
commerfordelivery.
This Authorization Form was provided by W.wammrdnomv G RaH K341C0
was executed at Pnxwrrm.emq Baker Funeral Home
nwin M1wzemren) 11 Lafavede BVeet Oueenabury New York 1gR04 and is sgned by Me funeral director
as release to its sixteenth
IMIs have received a completed copy of this Auth eambon Form.
Tha persons)IdentiThd below Ire Me primass ) in roam!ofdisposition, who by sgning this Authenticated
From, attests) M the accuracy and cornpreteness of the terminal addre rred in this Auf ranzation Form and
authonze(s) the mregasg.
SItelMthis z3 �di �UJt� .N1Z0..I
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WITNESS:
�aaa R Re
Funeral Honk Rea M01130
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