Biles Jr., Leonard D. Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745•4477 or (I518) 7454476 I (J
FUNERAL HOME: i<j D SIaJT A RETURN TIME: W/4- O
DATE 8 TIME REMAINS ARRIVED AT CREMATORY: 3-7- oz ",E
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
NAME: CASEp /9
TYPE OF CONTAINER: /IN aJM/WG C fn r� a ..(r,� lc�d Low
PLACE OF DEATHi 3J / i✓iL 0" A4 (J. d„s &H ; 1,,28Dy
ESTIMATED WEIGHT OF REMAINS 8 CONTAINER NI) / ZZP I�,
PLACEDIN HOLOt 9 q
PLACED IN REFRIGERATION: 9K
DATE OF CREMATION: 716174
TIME STARTED: I' YOPIIyI TIMECOMPLETED: gfri
LTD PLACED IN RETORT: I'45GYI MOVED: YII I L' aft
RETORT # IN WHICH REMAINS WERE CREMATED: SNr➢_
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.
�ql
IEW VORN Division of ON OW
m ERIES
STATE Of DIVISION Cf CEMEFERIEe
OPPoRIg"""- Cemeteries Ali
Tia ;sho4;: a�a
Authorization for Cremation and Disposition
This AUM WN Fornl must beoampla"a Sold eiarML parlor to dNlvey ar mu le far Gemanon.
D„e: Onoyzaza Number.. 7 11
Crematory Name:Pine View Grernatemund
octal 51 Quaker Road Qu6embuy NV 12804 Prow: (518) 7tl 77
CREMPTION 18 AN IRREVERSIBLE AND FINAL PROCESS.
Cremates IS GMea ON by placing the mains a the dew all the commit nothing Me mmom into a common Wmber whom,
they we earl to friends neat and Paine. The MM and Neap will lrclwnb end amrsume averyMinD More bow allr W 1,
wbtcb en all Mat will w MI1 all Cn gon.
False,N IXTMtbn,the uwmory mil take reasonable eflal 10 RTOve all of Me remains and other matenal from Me cremation
chamber, but some minimal dust and raakuew 111 likeay be left[Mill. The summary will sepank mason el and foreign Main hen
the rem ns;and tw mnidemM and fawned nommal fall oe alspowa dab reauirea by 1". The camera remains will w menfammlry
pUJWM shoo small piecme and paced into a designed consumer ar um. Cw W nmstns Rsnenlly an pulverind own no
alrpM fragment is recognizable as system Suue.
OPENING OF THE CONTAINER
The cnmatory may only OW the Wonder dolling the uncma human remins,in fmiid tiwmpnreb,such of to conPrm tw
hardly Of Me aattased Or W ensure Mat no malewl is encral whit mull Imul smarmiest or(bmaw his aemebry pmwM- N
human mains are delivered Ina canlalnerwhlth b not fuldi sacmnatlon such as anmanitl or rental coral Me
wnabryr requa MOMSmainsbss wil InsasukaWilca wrin and
Nacaph 1inrsal w Toe gaming ofe
Prmaiem arm rcanarem or remofal m remains won hoPrwwMd homre a wroea aaa will a domain aaay, rim digNyand respem_
IOENTIFICAMN OF DECEASED
Name of Trio d: Leonllld D. Bike Jr Marilel SMus. Married
Last Known Adarea:33 Twicrai Lane, Queenebury, NV 12806
Place of Death:33 Twichaoorl Lena Queenabury, NV USIA
Sec: ®M OF Age'. 83 DO6: Oy1011937 OrraolOorM' 07MM020 Eebnebl WtiglR rll
Cewnption of oYaVWM M e911U normal will M de4YMYJ.
Y 6 keg .dN C zc CUc n�
PERSON IN CONTROL OF MIMMON
(Pe/rd��(ral;n mnnolWalapaalbn. nLygloNEaMe ldkWbpl
X Iar:e are the daignatedagent of Me dmmmd designated in a will or anMdin&rumem aeaM sureuant to Pudic
Section 6201.
-OR-
IM'e have a knaNWge Mat Me dewaM aealM a aTMm Irmhument mrsuad to Public Heath Law Section 4201 or
WWII Pressing dlrecans far Pe dispxNon of his or her remains and Ill are lee confirms haisno pnmily under Public Hasbh Law
SOLen 4201 add have the Nhe to mandate common of the rcmome of Me sec seed. WMur steel to as the cheesed M of
olba:
Leonard D. Riles Jr
0OS-1S8&f(Rev. MRa) Pape 1 of 3
�Authoriution for Cremation and Disposition
(M I Ill rwbwi/p)
Me understand Mel ff Me r ns art not tl im within IN
Eaynaluematboo
Pine View Crematonum my dlelwseame remsns in
.n ereMeveble avam,w.m as q scelledM.
vwweoewma
CPFMAi OOMAIXEMM
(ippjFi QVE of Ma/a'MtinHl
An um to N wed as a container N M uenWdJ monaim has been purmeW M1pn
am is dearnpM as Iiflows
Ly'..n untlaalmd Met it Me um a two smat to weld Me attire aemebd demi d.W eddNmnl tgN bowman ime,WuM M Same,
syaa�.MumisrclptpuNueed. WYa uMneletd NMBta um is purNUW aaNervnse pwded
Mine View Crematorium will pace the cremered tmuim in
e fiHN bttmvery canlanar M dNWpy
msAunomadon Fam was pmmed py Wendy M. Bulich was euculad at
Regan Denny Staltool Funeral Home
53 Quaker Road, Queseadd , NY In"
and is sepmd My Me Nnenl mtwYer as wilnees to its execution
Mesa have recown a contusion copy at this AuNOWetlon Form.
The pxsonts) Identified below twain the demands)In wood of dlsposMlons who by signing this AUMorliattion Forms aumt(s)
to the accuracy and comp na Mthe Inbrm " CwMined In MIS AUMWSr Farm Said emissions)Me foregoing.
Signed thin 2M1 day of July s2o 20 n
Ronald Bibs /IdI'F'/JVX'
597 W Valley Rowel NY 12809-
Amen
snxnwm ar+w
rc....+um rcdvmr
Welly M. BuliM Wax
ll
w lgddt
LeorreN D. Sibs Jr
i—Auttloriratlon for Cremation and Disposition
rxwrtdom W mf Mmw)
Nurrdr: 108 Deg ow: A em
1. Apers do signal int nepumuedm PWm NeaM BxyMQOI(J):
x. 1M wmnng immune.
p.. its wmwng domestic Mather:
i. rgch MYWiNgild eighteen years degas or cider,
parent
6 A surrwinO aimliip Wl seam of We or older
A A lawfully apooMetl guln',
T. AYmormn(S)duty htl uciary yeINmof e ste or ele;door entitled m share In the estate arG who ishave tlmgt l n nWionce to Na deamw]i
a. A dean fMnd or relative who has executed a whiten statement an to Public Heats taw Sedgn 4201(7):
10. Atliiel M®l officer of a county or a public adrenal et)lvded pursuant b the 5umgam'a C Pdh Rdxoure Ap:
102. Any other per9on woo is actird on behalf of the o0ered and Who has e Ved a written atelenet Wcomen m pal Neagh
Law Section a201(1).
{� ( "' TREE 0ties blowing)
Its
I< ALL 100 mashy all final the hotly Of the dwasaaed does raw mntan a bMOW, owners mil pmMr a Mio call. acM implam.
Nva dews and mil any such mateMla ware mmoveo Pia to the exeuMal d Nis AUMozlatl FMn. Failure so mmove
mugM P to crmullon may nark In her an to tM camMay and consumers p mi.
vwe affirm that increases was been given to WWIM1�M. Bull
Ding the removal of any Mmnal proarry,or anyway soli ad wase which any"War Wining DMmw or any family Member 0 they
Worried wishes M polymer Pine View Cematonum
by not responsmle an Me removal of peanxiel kerns horn Me mn1rdess0 om due remelna OIMe dxmao. ParaWlMmIts In May
•with the remelt will M datmyad "a cmmetlon pra:as and a nbi n net M wed ready w c "o
ne•'or Hereby aummma Pine View Crematorim u
g m
tocmmam UPS Worths OFme
IJyI N1 McwaW.
( 0PTIONALf
lane hereby a dhome the named Nnartl director ro Morse Iw delivery m and cremation by an aMmab
rxmmry. It deemed necrosahe In Me opinon of the mu raw I of rector,and to amend mu tons to provide the coned name and
addme d such aXemam construct.
FINAL DISPOSRION
The Mason auMmrizeo M rea'ne tlro command nmeiro IXMs embedded M1cm tl1e umulcry is:
Nerve,Regan Denny Stafford Funeral Home, Wel M. Bulich
Address'. 53 Quaker Road. Dueensbury, NY 128M PMa: (518)7W-1114
The aemded rawer daeawneb Will M diapered do meaaW'.
Burial — Pine View Cemetery
H 1p pry teen tM amm named sM:e dew net teed auneeYcn as Its mesas]remains,
Pine Vlew Crematorium is Whmzed to give aaassion of
Its mmmnem Regan Denny Staffortl Protest Home bt dervem
in arean er by Mp mail. luaonerd D. Blles Jr
ewawow.�a
DOS-t896f(aev.( 9Ro) Paps 2 of