Gualtieri, Thomas J. Pine View Cemetery & Crematorium
Quaker Road
Queensburyl NY 12804
(515) 745-4477 or (518) 745-4476
FUNERAL HOME: -L f��eS���.Llt._____ RETURN TIME-
DATE & TIME REMAINS ARRIVED AT CREMATORY: ,_ 7) TZ( 10 Q�-4
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS: -
WAPP
NAME _ IrvMS LUNCITI,,F
TYPE OF CONTAINER: dw 6d
PLACE OF DEATH:
ESTIMATED WEIGHT OF REMAINS b CONTAINER IIO �L
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION: 7(jE)ZO
TIME STARTED: _ TIME COMPLETED: z' ccMyy
PLACED IN RETORT: _ C)D ry1_MOVEU: I:QO P� 2:)6Q11 R>�EA1
RETORT B IN WHICH REMAINS WERE CREMATED: p P r 1I- "T,I
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THANE448 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SHALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
NO York Saw
NEWjY Division of DWIMN of CEMMERiES
"'^ Cemeteries 9=`nmm` Aw ..
01
T.I�. Ideou 62
Authorization for Cremation and Disposition
Tnla AU on odm form must the complemd and signed Priorm Esllaery of mmins Mrrcmm m.
Data o1ali Number: oMt
Cmmalory Nurse: Part'CramOpy
Addrem: 21 OuM Road, Oumnan NY 1280o Pam. e_ (518) 705J077
CREMATION IS AN IRREYEMMLE AND RN PROCESS.
Cmme an wr out by Piai me mmame Oftlp deCea also Me firer lldderg Me narri into a cremered chamber whew
Iby am aublecmd m nomwe Mal and flare. The MA and name will Incinerate and conwme werylnmg serest lend and mi
AN lend are an Met All l be MR aMr nemmon.
Follwmg Cremation me cremamar,Am tells reasonable efforts m mmow an of be remands add cuter mammal from the cremation
atamMr, but some minimal dust add m5due Wn Many MT en Wiind The aemak win separate Inddodal and mrel9n maenm rtom
the remamaaM dre mpbemal and foreign several will M dlam Died requlmd by law. TheCrematedremainswillbemechanipuy
mfaenaed into small pied ,and plamd Imo a Answered Consumer or um. CemaW mnalm garwrally are puh'arlaad uMi no
smeltfm9mentmmcogmaabinuabla idesue.
OPENING OF THE CONTAINER
The crematory may only cpen the mmainer holding me uncmmettd human remai a In Iimiew awmati auCF as m wnfirm orb
identity M the aSW or to ensure mat no matenal is entluud which mghrinlum empmy9ea a damps the crematory pmOeM' a
human remain are delivered In a conblmrwhlch Is nor subble for cremation such or ceremonial or rental walaL Me
malory will require that Me remains be moved Into a auaable consumer before it saints Me mmaln. The oPonmg of a
consmer or me tranabr or remove of remains ad M WMuded M(pe a wNNas and All M done In bwary,win dgnily add rey d
IDENTIFICATION OF DECEASED
Name of Oewased: Thomas J. Gu n MwmI Seems Mamed
Mm Known Adores: 2025 Rem 9N Led 51, Greene d roust NY 12833
Place of Death W25 Routs SIN W 51, GreenfiaM Center MY IM3
SO,: OM Of wee: 57 Doe. 02/07/1963 Dare of Death 0711MOO Enmam M' 160
Oesmoron of®aNewm w in which remWIa NI M"N i
CardbosM Box w/Woot en Base
PERSON IN CONTROL OF MSMSITION
(Paraa'l(a)m author cfd MftW,ami ONE leMe lIXhlingf
amMb am Me 19Man acom of this eE dmgmW in a All or vn lnml lnblment erenNd dominant m Public
Heats Law Section Q01.
new Per knowledge M e Intl MNaead"fewb aWmem d a wman in puM$nt to Public Health
w Sion 4201 or
tamlrg dllxSona mrawdlapnmon dma or Mr remains and IMg are me p n(s)naalrg ordered under Public Health Lee
az01and hags Me might m wthonse showmen of the remain of to demi Room mmaonaMp to Me dxeaeed isu
Mum
Thomas J. Gualtien
DOS radii hey,. 04120) Page 1 of
Authorization for Cremation and Disposition
(IMMfiwn Me bar babel
Numbe::2 Descrlpdm: Elena Pleb(Boom e)
[T \ 1. A person tle s In wntin8 Pursuant to Public HAM l%x$e�San1]Ot(0)
um I
eavmg awnpan.e,
The,slurrying Marect o pager
]. Pny mr,yiy on IN engineered years of age or older
l Asumn9WerR.
0. A Sunni an,ng eqM yal M age a dExG
0. AIaral appointed guardian'.
f. ArtyWmonislcghteenyemofagaorokarertledbshaelntlbeabbaMwhoiWaredcsenin ralNoneM1iPbtlw Mmamdi
S. A duly apaiMal Muany dynamcal
0. AdM teMw MaNg oMsexwuh awrNensblementpumuantb Public M¢ LawS OonQOl(i),
Par A Mkt fieca officer of a aunty or a public administtebr egwnbd pursuant to Me Oumoaeb'a Carl PrcmJure PLl
last. Any deal pemm who is actiy on behalf of the deceased and who has exea@d a wirer st OM Wreuand b Public Heats
L.w sxmn 420171.
(IN ALL ThREE page uppowini
IA`A Mraby An Matte bmyoftlredereased deals responded a barriers,small PaM,poyarmll Avers"impienl.
On rad'raac9vcdevre and Me my,such materials were removed poor to to execution areas AUN Ntion Fain. Falmremramoye
NaG items prlofb cremation may result In harm W commonly
Ma co bry formal mal pemonnef.
di&i Am,N4 instruction bee bean Away to Roland G. Hi
�regarding the Rmonl N am MMMI Pool Or other thing oekern which any Min opn4p belwv or any kmey,member ofMe
Metal wishes to prexrv¢. %re Neu GBmelorY
is nor Nponsibb for the pooh of pardmad Items May to prop f or MAY tip remains of tM dereased. pemnal forms MN In Ne
rero r AN Me name Ins will be deYroyed by the cmme m Irroceds and Man not be reTmed Y uth formal
al Mreby a mr,may %re Vbw Cmracter
arowema.w
memmau MeremalmaMetl m5ed.
Li oanorAu
em,hamby authorize Me named wneral director to provla for Mail W and cremation lay an albmab
forma W If assmenececnmab y opinion of NeNneml director,and M amend ML farm to promos Me corset name and
,ddmFINAL olsposMN
Ta Mason aNM1odzef to pool Me panted ramtim N Me damesad ham Me aMMlay a.
Name: Cornwssial Furesl Car.
"di Oog Maple Awe. Sn O%irgs, NY 12M PH (510)passe N
Ta perform money of deceat wel be deposed of as Mloods
Name To Fmify
If fw my main the paean wnW Ypro dxe not fake praenoon ofMe model remand.
PImY Cmmebry is aNh W grey p nW of
the remains of nn=wrvrwmu ComssforM Funeral Care. led by&M Y
in pamn or 4 rearmed men. rvwvw�ww mmmae J. Gmtl
GGA10�f IRev. (i Pargat
Authorization for Cremation and Disposition
rtp�"ryl0 wroMM)
`�{Kµ�/_IMbum We Out ROD mull San natlaimel WMm 120 days W oremal
�[/ Pina Vim Crennanal
n naydspye pltlg remeinsln
an Inapeyple mennep wcp as by 661bnnq.
CREMATION CONTA NERNRN
Refer ME or me kamens
M um b be used as a wnUircr W dp Mussed rarulss has Wm Wrl'Aaaal lNn
ern is Mxnped eayloxa:
Wh InLLysUM that g On urn 'ts sea arml to land Na erMe Demerol rtmaihe an addhinal And COMIUM may Ce used M dehrely.
Mum Und yetpWaased. Wy ura�raUrMNMilnO Wll lB Wrtluaadn'otMrvrisBpmidxd
Pine VWw Crematory tall plea Ne aremehd remains in
wwauw�waa
e rlRM WnWrary mnUlnYbrdNluary.
The AUNor¢atlm Fern was pmviMd by Poland 6.Xtup xwewmlM
CanObdbbnadse Furual Care. Im
M3 Mane Aw Saralopa Spd a W 124N.
and 59 1 by the fusel dlRCNr as witseas to In Seamen��
INJe haw resaiwd a mmpMed mpy of this Aushodaanm Form.
The pereadal ldantl balm Were Na Wnonp)in earned of suspension,who by signing this AUNwf[ar/on FOOD,Senegal
m µs accuracy and lumpNbnass of Ns Inbrmatlon mmained In MIS AufMrleatlon Perm and vuNor s)Ue fongopp.
Slpnad NY 21st mYd July ,30200 /J
Elena Picdo 0-4j
2025 Rana INb151.0AenfieN Centw, NV 12M3 Y]� 9GW
man,
'MTNESS:
ir " """ """'"a / 5734
TIwmY J. Gualden
00S 189811Rev. CA20) Peal