Chylinski, Mary Anne. Pine View Cemetery 8. Crematorium
Quaker Road
Queensburyl NY 12804
(518) 745-4477 or (518) 745.4476
FUNERAL HOME: /iBMffP{tAib
_____ RETURN TIME:
DATE S TIME REMAINS ARRIVED AT CREMATORY: y(/ 7U "'
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
NAME Rey 9NV/E/1 CN4ll uvr CASER IrD
TYPE OF CONTAINER: /a Nµ� (..:_ .w✓
PLACE OF DEATH: �VAED / S'1'Ui0A= pJ
ESTIMATED WEIGHT OF REMAINS B CONTAINER
PLACED IN HOLD: of PLACED IN REFRIGERATION: _ �I�pu pal
DATE OF CREMATION: _ G pal
rh
TIME STARTED: 1-� AP
COMPLETED: II'Anr1I
PLACED IN RETORT: _ /G:FO AP MOVED' l�Ar II:p
RETORT 9IN WHICH REMAINS WERE CREMATED! 1-
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 08 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SHALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
EW YORK Division DNISDR�OMC"EMnwrinEs
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Authorization for Cremation and Disposition
this ANDO on Form must be complMd and signed prim to Mlwq of remains for aremaEon.
Date: 0711 Burger 00
Cranemry Nyre: Pine Vew Cremq
PLdress: 31 Graker Reef, QU mWq NY 13804 Phoce, eta) >aSMP
CREMPTION IS AN IRREVERSIBLE AND Fi A PROCESS.
Common'ffimemo Wl by plaurg Am remains of off mora d also to mmalner MNlrq the remage nth a c mensmancer stare
May are mdaicmd to mime beg so flame. The Mat and Dame will lnNmnb also cwrawna*w ing except bone also maml,
which are all Nat will be Ina affair crematon.
Follwengvmg ,Has Person,will Ake reasonable eRwb Is remove all of he remains and oiler mAnalM1om Me chmaber
cM1amber, bN same minimal dust and waieve will likaly he bh ceMM. The sensors vell stases InafeML also Answer meant ham
Me remain;am to Inudenral am foreign manage vnll be dismissed aces regulred by law. To vemgPo remaire will be m ani N
pulvemed Imo small pis so placed into a destroyed mlUiner or um. Crammed oral Small lY are pules all no
sing le memeMb mmgnbabm as slieMel Cone.
OPENING OF THE CONTAINER
The well may only open the mmminer hoom the unuemged human remains in unwed orwmalanres sear as To cognsh has
iea ly of Use dismissed or to ensure Metro material Is encased which mtM inlus moderate or damage Ate cremrtary prcgrly If
human remains are dellwred I n s mnelmr which a net suitable M CMnNan such as wr onlal or rental casbl.No
wmmeary will small re Mat Me remalmovedSuitableSuitableben moved into a Suitableu container Were It acpb immune.Mine. The coning of a
lmlmr or to transfer or resi of lessina snit be alaugM we a wonder;so Mu ce done in pnncv, ah dignity and final
IDENTIFICATION OF DECEASED AAge
Range of Dewaw Mary MICrNAgti Mage t a. MarreO
4g Known Andrew I /Raoul. S mmm��Man�/g�e NY 12M
Plains of Deana: �SA IV djWy
Sex: OM OF Age: tad DOS 84/19/1980 Dgeo(NMb DTnlnWO Estma greet: fo
Dimensions of make inerin which remgrs trill ben"Mat
Cardh°ard Box wlWooden Base
PERSON IN CONTROL OFOSPMMM
(Pomsm(a)vi girth Wdiapaadan, �IONEOIMa ldbwrgf
I emM4 tam to deagneled pent of the dsmased Methanol a will or written lm eta gnl manages pursuing m Public
Health law sector alol.
OR-
nevem knowledge MmtwdeWalgoa ea wrong slo umeer Nmu=toPlGk Neant law Seddon azol Ora
van mnUmmgmr Ions for the dlspoaltan Wh'*or her remain.nb led are"parboxi having on"Under PAIC Health Law
S ionazolandhawme WhtmaaMor¢eciematonMMemnalna MMadeceamt NYIOur nlvtlonsnlym Me eeceaaee II as
rotawas
Mary Mrase, inski w
DOS IBMf(Rev. ii Page I of
Authorization for Cremation and Disposition
Phol tin me act eemm
Number O np, Ch la Chrimo15puoel
1. Aprton besgna111n wnUnp purment b Public XeaM taw Becalm 03p1131:
E. Tna Panel epuuee;
U. The sunvivm;E eoc paMer,
]. My suramal chill aghleen ywm of no or older
a. Aswaying parent
S. A rural stall ng diameter"am of aids de older
S. A IaMUlryappo road g notin'.
T. Any deal eighteen years of no or cater mail b sham In the estate all who more closest In mail N Ca deputed;
e. A duly appainal fiduciary of Me estate)
S. Atlme hand or mleUrawfio has emoted a much statement pursuant 0 Public HeeM Law Soccon IEOTyTJ,
10. Ache'more dfia3r d e Adurdy m a public ad in moral airpsnaw punuaM to the Oumoyta'a Cash Pmmdure M;
IM. Any enter Wi MO a Wool on bald))of Me demased and who has exmkd a v nsab pursuant Ad Penn laaM
law section 4E01
�MAYFE wore Meta pl
Web Wendy arm tat me body of Me damaged does not conbm a baaerv, baMry ani power rou. adapc4va import
treasonous MVlm and Met any such malenaa were remoen partner' axeallon moms Aumwkellen Porm. Paflumbxmom
Me I proarmmmmon may moult In harm tome monetary and cmmabryrprmannal.
WJa arm not instruments home bean Mean to Rdtam C'. Non
Wall the removal of any pwa M prtpM a der mina amar wlhtb my p WgNrl Pool m any omi mail Mine
Motorola)M.lga by premier. Pam wFa CmnNory
m nmresponubte rorme remomar ormnonal ltemnhwn Memntaamrorfmt Meremm�gorner dsmWeWd. P.rem.l Mm.MN InmI
f orxi mmalm W]lMdaeboyadbytaemmadonpr emandcannMMmMevadN rarmam
NW hereby authorhs Pine Poe,Crematory
N+nM menu
bsmnM Me Mmlm Mme MwaM.
I OPTf0NAp
Was,Karl aumordo Me named bmnl dlrmhorro pmvlde for delMry to and cinmnon by an alternate
emmMq,N domed necmury In On opinion W me tumoral dlracmr, and b amend mole form to paral Me tail name Intl
address,W such aMmab more .
FINAL OISICSITION
Ter person sentenced mmlve the aemal remalm all.dmoed Man tIhe"mebry a'.
Name_ Concessionary Funeral Can
Address, ONMal Am., Santcge SpMps. NY1 M Phone. Ist915ea�Ma
Ts,nemamd remains of Mitsui all bW dip etas Waves
i1 Neon To Family
If b any ream Me person named move does net Ws,"sm on INMe ram nyl
Poe (thermal aaNNaiM M glue possasslon of
l
the mnaamm chiral rWnn Cvng MM Funeral Cua.laid by demry
In Terson or by named mall px�wmxaml Mary MAhil
DOS-limit lPev. ( ipl Patel
Authorization for Cremation and Disposition
I! NA 91
ulMnbn l had of Me remains ere not claimeE dean 120 days of cownwe r,
Rrc Yex CremetOry mayti0pose alG4 RmaA91n
Bnlrrandiabbmanner, 9uCM1 eabyaOeXenrg. nunarcv.vvn
CREMATION COMNNEWLRX
tndaGNEMMB MbwInN
_Mum la Ca avel an a ronfelm M ft pBmaatl handed tug town purMeeM M1pn
aMKdwii4 asftlwn:
InM undhowa d Mine NB um a be anal W now Cn wNm unowed mmBIM,On Wood"npa container may be umE for calvary
LMun bnNyzr WrCreEBd. IN uWem Wtl dnoml9Nr au woOsnsopry
`` containerPhew tlruMmry will dam Me nmarBtl RmaiM in
a nail porary container hair delivery. comer
Rolland G. XHON
TheAUMOAaatlon Form was poWedty waseaemlW at
Compaaanmte Funeral Care, lnc
IM Maple Aw., Sam" Sgiryn NY 12M
�nwewinww
and a alernd by Me frneral direMf a9 money to is indcaaon
INde him Rp'My a WmpMed c py of NIs AUMwfrodon Form.
The
rwards)In conderol of
aine Men.who by a
W Me accuracyOM cmq nlua 0M ipnlermatlon conalned In Mls Audontratlon Fmmn and suNorhei Ore fore binQ. sl
Authorization� ea a
nada of le 13M tlaY JUIY ,20 Ch
cnnau Wand: Ln FInan�P�
i vniMav Ame. saram9. spnrga, xr tzcas
WITXE99: n re+el Ro O[C.wwww
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MM G.X d
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Mary AneChyinek
DOS-10Ni.f Ilse¢ OM201 Pa af]