Mazurek, Kimberly Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745.4476
FUNERAL HOME: —�t�it ... __ ._ __ RETURN TIME:
DATE S TIME REMAINS ARRIVED AT CREMATORY: 7IS� '10
NAME OF FUNERAL DIRECTOR OR REGRISTEREO RESIDENT DELIVERING REMAINS:
H2[Iq fA rFG
NAME: _ <'ZHNW kKV(.tV CASEE 91
TYPE OF CONTAINER: ALW- i N (L vq( MIN 'MI lvi6m-
PLACE OF DEATH: 107 f4%U 4t * L z.A - 41 MI LMry
ESTIMATED WEIGHT OF REMAINS A CONTAINER 290 (L- hoollIF
PLACED IN HOLD:
PLACED IN REFRIGERATION: ZMOGM
DATE OF CREMATION: 11101.IZD
TIME STARTED: Td� Ean q.S-04n� TIME COMPLETEOI
PLACED IN RETORT: _ 'I:tn MOVED: llmtT 97A/m
RETORT 9 IN WHICH REMAINS WERE CREMATED: LER {E^EA Alf
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE:THE CREMATION LOG FHA" BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
aE�m
ZAnvo onic Division of orvB OFm MMF
oP mem. Cemeteries
Trialo .l51840 bagel MY g6
w,w.a�m.ga
Authorization for Cremation and Disposition
The AUNala mFarm must the canpbba and signed prior to dWwry of remains fw cremstlOn.
Date: T� No~, 3101
CrwmM name: Pine View Crematory
Quaker Rwd. Duwmbury NY 12Bw s16)eSMn
nadrwa: Pram:
CNEN. ON Ie AN IRREVERSIBLE AND FINAL MOCM.
Channel is canned out by pe°ng Ire remains of Me accused and Me mneiner hodkO Ne nmana Into a vemmkan chamber Mere
may,am subjected to moral heal and flame. TM Mat and nave wig lmiM and commands ewryW"eaMpt Mm and meet,
w cn an alltl evil be left after Cleveland an
laovdng mmM n,Me pHnalan will take re6ammbie Mom no removean of me remains and Giber malenal hem the oemanan
Wmber. bud some minimal duel and famous wln nxaiy be eft behind. he game"will agenda inddantal and drought budget door
he rermlna and the mciaerul and roreign material Mil be aiepmod gas required by law. Theoermteare OMMIlbem)mil ly
sugar into amen pemaend placed into a arranged vmteiner or um. Command remain pe lly am pules durMl no
Nnge Fragment brecognlwbN as sWWI tl ue.
OPENING OF THE CONTAINER
The crematory may ont open Me commoner Mining Ire un emaea human awards in limited ararnstanma, such as to confirm the
Ideal of the Mvwa d or to ensure that no malenel a arranged Mior might injure emgl°wee or damage be crematory prowM If
human mmsies am Nllwmd in a mora r which is not someone MrcMM2dm such as ceremonial or wage casktt the
cmmal wilt s uim thattle nmabe bib moved Into asuleble wM imrbeem it acnpu Me remains. The opening M s
wetting or the trap e'or removal of remains will be condul Here awMess and art be done in priu6y, Mn dignity and using
IOENTFOATON OF DECF ED
Name of Discussed, formal mek Mar lSetus: 01mom
lM Mom Audi IM Gurcel Cl..ML 8.Wlen tab. W reap
MI of Danish.gravel Col As Ae IF)
$ez: OM OF Age: Sa CCB: 44111 Dale of 0eelh: 7011202%) Eaumud VdepM'. p50
Deeuipdon INwkN¢nulner in Mon mmsnawttl m delivered.
MCMrexeium2CmmW UNIMhvw]B�Mm
PERBON IN CONTROL OF MBFOSTION
(Pnun(al M¢MrdW dyav2wr.�ONE IN th ldlaeuigl
Iun'Yhe am the designated agent of Me Mmeud meaneed In a win m woman Irish urnam ev pusuwn to Public
N..ml cow Seaon 4201illigarr .
MJa new no knowledge Mat the aema8e°eysNed a written ineWriem pursuant to Public Hearn lnr Se n4201 or
Mil comer aketlima for the aiepmlacat off his or her mraaina add live am Me pawn.) having p ncrily under Pi Hwm taw
Section 4201 and have Me right toaNlertm gambol Of Me mmaina of the managing hill nlenomhlp to Mrs deceveed Is ss
fellows:
Mil Muurek
0(Cl310eJ guar; 08115) Page 1 of 3
Quthorintion for Cremation and Disposition
(e the folloadi
Irunnak enlaMtlat irrne rem4ns an na tlaimW whin l3o Bays orvemaYnn,
vme View cramamry
.
mar eiapaae of the rem. .in
dv- r
an irreWeaape mane.., cocoa awbscattering.
CREMATION CONTNNERNRIN
(Irvtial ONE draw Addeni
An um to be used as a contaner M Me carried n ins has been purchased Mm
and is enoibed as blloas:
head Undignified the it tlw um u bad smell b had Me walla cremated rdrebu.an a6]Ilaul rod conu'vcer my as used M"Wery.-OR-An inn is rM yet puNwed. IMN undidl Mtlat M no um purchased or alemiss pmneee
P'uw New Cremaluy
win pace me vemaMd remand;in
Awado dew
a rgidtempar.rY container for xfrvery.
Patricia Miller
This Autlwrbetim Form was provided by -ua;eaawted M
Miller Funeral Home
Si NY3 RN 3q Indian lelw, NY t2M2 esed c was
rwnnaav
and is signed by fine Nnere M l eii as ress W ib mearnoni
VAY nave repNed a somplai copy of Nls Au herbraddo Form.
TM pei idaMflad below IWre1M Ponoinsl in eontrat of disposition,who by signing this Autlrorbtlon Fomr. aangq
W the accuracy and wmpMaress M the Inlmmetian contained In di Auawmaaon Form and suindand lgs foregoing.
Signed this ° darts JUN . 20
Nnstire Masm .. TT ,nlrwf �Y�nlVwa�
Akhw
Ali
Awasa
paWw Miller
2K6
fti
NlmLeny Nasurak
OOS1B04t(Rev.0.W16) Page 3 of
Authortretion for Cremation and Uispoaitlon
peen dote ma e'dd.low) ,
Number ] Ceecription: Nlxe
1. A pares designated in wing punuent ad Pi HaaM Wx Sector 201(3);
z The surming spousei
]a. The eNVlving domestic paMer;
1 My euri child eighteen yeah of age w alder
A NsuMWng parent
6. N shootig sming eighteen years of age or older,
S. Alawlully appointed guardian;
r. My orders) eghtwn Years of age or drier emitted M sham in the estate end who steers dogged in relationship m hie deuesM;
V. A aq appointed fidudery cr the estate',
S. Adore Handar relative arms has eaesped a wmhn movement irmwant to Public Hector tear Becton 4301m'.
10. A&ld hKdl officer of a county car a Muth;admini8bdor appointed mustard to Me Su moats a Court Procedure,Ad;
10i A"other person and is acting on behaxof Me depeased and warn has erected a wrAkn statement wrwam le PutVm H®IM
Law swim a201m.
yBw.�ALL THREE a Ma distinguish.ciciu-g4 IM4 hereby affirm Net the body ofthe de xa sed does not conmin a mMry.WIIery Wi power owl, rad'wWps implant
or nightmare passe aMtlW any ai mationaleware remained pivp the eeev4on cf Mis AUMortratlod Form, FdIYA Nr Ngmw
dues Xems pbr to cm on may mull In hum b Me cmnaroryand cmmatory, unonrel.
r-� Parkes Millar
IM1W affirm Na Instructions have been given b
regarding Me mrwwl ofany psommal pryrero mintier Ming mvalue Much any parson signing New or any mmiTy demur of the
Pine New Crearmi
deueud wiMesm measures.
is not responsigelm Me removal of personal items from Me mnmNeror from the mmLns dVe daceesed. PBrwullWna MM1 In Ms
cmurcr orwiM Ma remaim will u da4oYad EY Me cmnatlu Prouaa aM unrM ba MMwd Nbr cmnatlon.
yi-- Pine Vim CmmeMy
fte,hereby,authorise
R Mai
a contrast Me romalru ofMe deuuted.
FNu(AsPOSmON
Tows, mason euNorisad 0remtx the oemaM man®id,of dgaep horn tla am Tar
MI9x Furies Home
Name'
8357 NYS Ri 3q Indian feu,NY 12842 518IM8,0311
Adhere Plme:
M memekd mrrawn;0 deadaM wil u doad of m Mbm:
Ra bK mme
5br aiy rm>-^Me agreed n l above due Notlabpwnakn dMe as=Nslemdna
Rne sites,crBmabn IF aMetrp to dw{WBBFYerld
to ama+n
maremalra to Miler Funem Home by ddyay
in pawn or by registered man. Pswwiwesw
KM[edy Measures
ryn.aw�1
WO 18 ftRa. MIS) Pit ad
y
635ISbRRoure 30, Po6rn]l9 •WianlaYc,New Yohl}892
518644ppI1
Mirlue]MJler'Rxy MJla
CUSTOMER'S DESIGNAT ION OF INTENTIONS
Name of Deceased: Naoeas Mae'^e'
Cmnation: 7a 0 Eme Vim Crtunaboty, O cenobi NY
&heAtlN G and L 0,
Manner oMisposition ofCre n tim:
Model at: pRemmto: an.00g e n
Datombmenta ll Wer:
Disposition of cremaim designated by: �= -a{ �
is�' ��^•, Gy��{„ UT /�SAOI
tetepww: eat°vests
Cremams which have not been claimed within 120 days from the date of cremation may
he dhWp of by burial.
Name afFurewl Di met Pe RMYla
Sgmaw e: A Dare: rrermep
TOBECOMPLETEDFOLLOW GCREMATIONANDDISPOSITION
Crematory Name & Lacatiem Pine V Cmnnalorv. Quearalnuiv, NY
Manner ofDhs ositionl
Location: Data;
Petmn Making Disposition:
NAME RE41TlONSHIP
A
saw•lv..,a,wue emu,.... an
RECEIPT
Cmm�w WnrvzJ MyNar S m a f�l ive0