Talejkowski, Sandra J. Pine View Cemetery & Crematorium
Quaker Road
Queensburyl NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: R�� RETURN TIME:
DATE B TIME REMAINS ARRIVED AT CREMATORY: 71101 W ?:%A7
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS
NAME: SIWKA TR/ rraKpv CASER 0
TYPE OF CONTAINER: 4/FIN`i-I (uF�[ ti J iN x�
PLACE OF DEATH: nfllst -�`f t A (liar @4 tY (x8l
ESTIMATED WEIGHT OF REMAINS S CONTAINER__ /SO )(r
PLACED IN HOLD:
PLACED IN REFRIGERATION: 3701
DATE OF CREMATION: :7=//- zFzr7
'{
TIME STARTED: 74� TIME COMPLETED: 9yq�
PLACED IN RETORT: llt� MOVED: >75� - R
RETORT # IN WHICH REMAINS WERE CREMATED: Ar: p. lf "¢
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE, THE CREMATION LOG sxuL RE RETAINED I N THE PERMANENT FILE OF THE CREMATORY.
Nis
,Authorizationfor Cremation and Disposition n.E�m. aa1. Win.„u
°hist"Awnre
such,1 )7t6iis
This AuModza4 Farm must"eompletedaMsgnedpNwro defrearF of remains Wcram .
Cate: 7110fu Number. gel
Crematory Name: Pine Yew Crem=N
Address. Quaker Road, QueerKOUN, New York 11004 Phone: 5181745.4477
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation Is Cartled out by placing the remains of the deceased and the container holding the remains into a
eemason chamber where they are subjected to intense hem and flame.The beat andflame al IMnv and numbers
ryMing as bone and meal,wNch are bill that NIB be NR athr cremation.
Fol towing ere matter, In a crematory wil l to ke re atone is le tea nit to rem ove a n of I he is his t ns a nd at her mate ria l fro m the
cremation chamber, but some minimal dust and residue will likely be but behind.The chummily will winners incidental and
foreign material fmm 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 plawdayi, a designated container or urn. tmnated
mains generally are palwrized used an Angle Ragman b rampd Me as skeletal mate.
OPENING OF CONTAINER
The crematory may only open the container holding the un-cremated human remains in limited circumstances, such as to
confirm the century of the deceased or to ensure that no material is enclosed which might injure employees or damage
crematory property. If human remains are delivered in a container which B not suitable M cremation such as obemonlal an
rental ,the aematay,will require Mat the remm,be mwetl into a suitable mmaintt belwe R accepts the remains.The
opening of a container or the transfer or removal of remains will he conducted before a witness and well be done in privacy,
with dignity and respect.
IDENTIFICATION OF DECEASED
Name of Deceased:'ro(1r -To A kOf jzizik Memel status: M
Last known Andress: 7 C1 � j SA L#A) r G teams FD u D AN 12101
Plateaus of Death. A 4�h mr
sex: DMO Age: -1Q DOB: g1111ii Dates OeaM: -4l pJ70TO E metedwftht /y bs
Description ofcasket/container in which remains will be delivered:
CriTudentedCadboz III Box with I d SmrmarkMdl If 384808
PERSON IN CONTROL OF DISPOSITION
(Person(s) in control of disposition,initial ONE of the following)
I am/We are the designated agent of the deceased designated in a will or written instrument executed pursuant to Public
Health Law section 4201.
-OR-
C(11 I/We have for knowledge that the deceased executed a written Instrument pursuant to Public Health law section 4201 or
will containing directions for the disposition of his or her remains and (Continued near page)
a -Tn1 -kot,��bt
msrwanlw..avlm
I am/we are the Ferri having miordy under Public Health Law section 4201 and have the right to authorize cremation
of the remains ache deceasi my/Our relationship to the deceased Is as fall
(Insect fmm�t2he list bribe)
Number 3Oeamptdrm C� llt nlCa{p/—
A person designated in writing pursuant m Publb Heats Lax sectlpn 4201 (3)
Z The surviving spouse:
2a.The surviving domestic partner',
Any surviving child eighteen years of age or older;
s. Asurvivingparenb
S. AsurvivingsibliNeighs nyearsofageordder,
S. A lawfullyappdWedigardiarr
T. Any pereon(s) eighteen years ofageorolderenhibeito share in measure andwho islafecimestin
relationship W the deceased',
8. Aduly appointed fiduciary of the estatel
9. A close RlerM or relatrvewho has a Wed a wWlen ldatemera pursuaW W PUd'IC Health Lane§4201(i),
10. A chief fie uh officer of a county, or a public administrator appointed pursuant to the Surrogate's Court
Procedure Act;
10a.Any other person who is acting On behalf of the deceased and who has executed a wrmen statement pursuant
0 Public HeaHh Lax§0201(l).
(Ini(brfALLTIflEE%tire JolbwMpf
Cy l Are hereby affirm met the body of the deceased does not containa battery, battery pack, power cell, radioactive
implant,or radisa ive device and that any such materials were removed prior to the execution of this Auffirmalwn Form.
Failure to remove base hems prior to samurai may rewh In harm to the crematoryxa oematory persomed.
Cry I/Wehere" affirm that instruaions haw been given to(mewwwv, CouMROMertv#14100 regardingthe
removal of any personal property or other thi re of value which any person signing below or any hmily member OF the deceased
wishes to preserve. rmimrwmmel Pine thew Crematory is not responsible for removal OF personal
items from the combiner or from the remains of the deceased. Personal hems left in Me mmaner or with the remains will be
removed by the severance pmcea and cannot be rWlawd after,creme n.
I/We hereby aumnrlre Pine view Crematory mftt mmaima
t eeeceared.
Hnu OIYOsmIXa
The parson authored to receive the cremated metal of the deceased has the cymMdy re:
Name B F
Address 11 "heads Strearst. Ornamentals, New YOM 128M Prone: (5181 Mi-003
The Cremated rerre arm adeceased will be disposed of a6 follows:
Realm to family to be decketl
If for any mown Uri person named above does not take possession OF the cremated remains,
h authorized W give appearance of the reuins0
Owes raw, el Bker FuneralH by delivery in person or by registered mall.
omusumn.uvwl r T l Y au •vt , a. .a t
a., v
- (Upyiyl rM1efdbwln9l
C vVi INJe understand Nat If Me remains are not Wined with 120 days of mandate
lNw�+bry N.mb Pine V'rtw Cremarory Army dispose of Me remains in an irretrievable manner.
suit as by scetMnng.
CREMAT ION CONTAINEWRN
I alrNEof Mefi4bwirpl
An urn to be used as a container fir Me chrreted remains has been purcheead from Baker
Funeral Home and is described as folbvs:
INJa understand that 0 Me um is for small is,hold Me brand cremated remains, an additional ngid combiner may ba used
for delivery.
-OR-
!�2 An um has not yet been purchaseU. IINb understand Met if no um Is purchased or otherame started rm.mmwr
vnel Pine Yew Crematory, will platy the rremxtetl remains in a rigid temporary
wntaioer for delivery.
This Authorization Form was provided! byMmaamwmmel Cassia RaffeM1v p14100
wasexecutedd[pwNms,w.el Baker Funeral Home
ImnawlimN..aw.ml 11 taarveHe BtreeL Oueensbury New YOM 12304 and is signed by the funeral director
as witness to its execution.
INJe have summit a compared copy of Mis AuNrrizatain Form.
The person(s)idanflfred below,ssome the person(s) in Conhpl of disposircon, who by signing Mis Auhonzation
Form, aftesys) M Me acoufecy,and completeness of Ma information contoured in Mis Authonzefion Form and
auMwlza(s) Me foregoing
L§rRd tlNe�day rf �IkAaa MZ.
nwJa Mrs
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WITNESS'
Cassia emRallityr
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rwicxmwrwed�xam. auxwawruisM.Nw
Funeral Home Red NI130
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