Futyma, Wladyslaw aka Water Pine View Cemetery g Crematorium
Quaker Road
Queensburyl NY 12804
(598) 7454477 or (518) 745.4476
FUNERAL MOMS: _ �mgD'kAl
RETURN TIME:
DATE S TIME REMAINS ARRIVED AT CREMATORY:
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
---_—__ `, 1 Pouplro Llgy._—.—
NAME:
W. _ l&f-s ay._
TYPE OF CONTAINER: _C'•vr __—CO _
PLACE OF DEATH:
ESTIMATED WEIGHT OF REMAINS 8 CONTAINER
IN
vIgCED IN Halo: �
PLACED IN REFRIGERATION: _ _._ 2:30
DATE OF CREMATION:
TIME STARTED: _ 7. ZDGY1 TIME COMPLETED: QFDFl(")
PLACED IN RETORT: ___2 _RAtt MOVED: GO 2200 1plr�' $� n
_ T"q RETORT pIN WHICH REMAINS WERE CREMATED: �pP�
DETAILED REASON FOR DELAY IF HEMP INS WERE CREMATED M ORE THAN 00 HOURS 1•
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION RE qm TION LOG SHALL BE RETgxED IN THE PERMANENT FILE OF THE CRSMAYQR
NEW YO0.K N OF Cn.� ksmm
STAIFOf Division of DNISN)N OF CEMETERIES
° T Cemeteries 99wea 9 rmN�
T¢MwN)'mo ram
orro MiCeeaae
Mom
Authorization for Cremation and Disposition
This AUMOr RUM Form must be complabtl data signed prior b delNery of rename for
clnmAon.
Owe: oIW moo Number: DlN
(wmalay Nama: Pines View Crem
Ackdrom 21 OuW Rent, OumMWry, NY 128M4 Phi_ (SIMFue TI
CREMATION IS AN IRRMMI& AND FINAL PROCESS.
cremation Is armed out by placing the remains ofthe deroa and me Meet boleng For snwne and a vemabon Wnbx w mmy
mev am aublecbtlrolrlkn¢e lleamna name. The heat and Mn$will handrail and command Me ina aMambdne and M MI.
which are all dart wig b Ln aNr orenanon.
Followingnerhatom the chembill take reasonable eldMd removeall of My remains and Mhermadnal hen me chemaxon
chamber. bit some minimal dust and residue win Will Ieft behind re cremwon will sequence mudmbl and faegn mwenal Man
Me remains and the inaMmal and foreign malenal will be actual l of as natural by laU. The oamatetl remeine MII be mechani[elly
pulrarimd Imo small phase and planed Ind a deoienadd ancestor or um. Crema ed Heal wmanlly am puHrtlaed until no
waste fragment Is recognize Me as a select l Msua.
OPENING OF THE CONTAI NER
The oemwey may only open me mnniner holtl,ng the ung moved human remain In limited nrwmstimade each or to WnRrm the
tlanuel decal ore ensure mat no national Is endmedwerh mgh InIum emppveea or damage the crenadryprcp "
human remains am MIInr Ina container which ill not suitable dr estimation such as ceremonial or rental Omni the
cureariationy contvneo Will Ma requiarhat Me eol'as remaemoared l FaInto
mMusbdbeen consumer
aaerse rA Hearst;line rea
artieal The nTFd aPomng Me
gniry aq rwgq.
IDENTIFICATION OF DECEASED
Name of OBteesed WadYS arm Wader Phil Minguld de: Mamed
Last tNwm Padres;: <N Chunk Street Sunray Spings, NY Rafe
Place of Demon: Home of The CmwJ Shapnad
Sex: El OF Aga: 99 Fee 12/19/1920 Date of Deem: OIYo=O Eabmame Wartim /(90
oammeon of aaMN¢nlamer in which remains w it be dwiwrtd. IG(�CQ/n1
Cardboard Box wNJooden Base Ltwig . Vra flop.
MMON IN CONTROL OF DISPOSITION a
(nmerre)In contM of wspicial m al ONE tilde AskwaR)
shNJe are the extended agent olme rbnSeetl mandrel in axill orw*IMn instrument executed puvuantd Public
Heald few Saclbn 0201.
q
OR
Ar- man have no knowledge mat the d_aasedexecuted a written Instrument Summit 0 P✓lo Health law SeNm 0201 ma
wit normal erections for me dispersion of his or her remains and Infix are the Feel",no energy under Public Hearst I8ry
sxDal 4201 and ham the right to sumwbe thermal Mme call of the around Walter miaonship to Me deneaed M as
follow;
Wladyslaw aka Walter Futynna
005-tgdg-f(Rev. gli Pegs 1 of
Authorization for Cremation and Disposition
prmwfM me set Inputs
Nw 3 Richard P. Funeral(Son)
1. Aces dmi9natetlinwnbngpursumlro PudicH MLa Seaon 201(3):
r. no survival spouse:
St. The surviving ecmmi partner.
3. A"Ummigchild egllwn mars 0l age or olderl
l Asurvivy parent
S. A Miami sibling eigNeen yew M age Or doer
S. A IevRUlly Moral guardian)
L Any Lerson(s)eghl Mass of age or ONm m atlerf W Sham in de estate and"a dw dosed in ralermffiip W am tladal
B. A duty app0inteE fiduciary 0l the adds
a. A UCee wood or balance who Me executed a RMhn statement punuanl W Pi mSM Uw Sadon 4201
10. A chief fisol officer of a county 0r a public admen armed appointed pursuant to the Sangel s COud PIOCWure Ad,
101. Any Other person who is acting On What of the deceased and who has executed a written datwent pumIOM W Public HealW
LwS ,On 4201p1.
fOSSMALL THREE mi harrowing)
F'r` ireal affirm hat Me body of me demawd deep not contain a baery. Mhery pad, power net relwN"import
w radmacee edevvgand Wa are such materials were removed promo W¢Potation aNb Ambassador Fwm. Fallum W mwve
Moore Items priorW more n may msuM In harm W Wacenti and crucial pamonM.
FIF Inches afimr that instrument have Men green Rolland c. Hoeg
regarding Otte moral of any personal deal or Manor µ'ing of wall which any Gerson agmirp b&cw«arty Wmiyngnbwatle
deceased wishes W desnal. Piney Crematory
is net mspmnd s forms numbers Of fiereonal items horn Me conteim w from We remain side dcaeud. Pemaul 1pma Mfl In Me
coMa�ltner orxiW tln mmelns will be tluYgetl by µs cnnutlon pro[as¢ aM cannon ha nWevad aaarcremailon.
of If hereby memories Pine View Crematory
icwmµw W deal Me mmmns 0 Me mormsed.
r�i OPnONAU
Islas hammy ambushes Me namW Nm ail director W provide for delivery W and cremation by an alkmame
mnmary,If dammed Midiry In Me opinion of µe Nmeml dimmer.and W amend MW form W prw'Ida µe correct name and
address of albmabs Monetary.
FINAL DISPOSRION
The anon announced W receive the[resumed remains of the dema¢eo from Me oema try is:
Name'. Compaeamw Funeral Care
Address: AdS Naps Avn.. renal Range, W 1 Russ Phone. Is19)r�aM1a
no cmmwdm rem Mdere w will be olapOW of in Wllwn:
'761ueN 7
If be ere weon the mlaon named answer does rid nlre ppetesam of the cemaM remains,
Pine craw Crememry 'ggyMpped m Son pus ssim of
rcewnvww Me mmeimsb Cons"ssimw Funeral Cal We py odfncry
in peson or dy eqiwmd mail. mveamnwm lMpanlw she Npher Futsme
DOS19964(Row W30) Pedal
Authoriution for Cremation and Disposition
f�maMxnwMp(
JUF gets uMersleM met MN¢remains are am aelmM v.Mm 120 Nn of vmaaM,
Pln¢Vw Cremalary
rreY assume cithe minim In
an umuwva0b manner,such am by¢wll¢nng.
CREMATION CONTA NERIURN
((SgSf ONEof M&Wmvhgl
An um to be reap a9 a mnbiner he had pemalaE Issues pm been puMm kam
and la Oawided as follows.
War understand that R the um is red wall to held Ma entire contend remains, an addearnal]C Cworher may be Mal for Mrtrey.
-OR
PPP um i9 m[p1puM0sW. INp unE¢Bbnd Nalifno um 0 puMmeE Ot o0mrw'ne pcvCed
AM Visa, abry still player be answered remains In
a add temporary cartel As barely
This AvtNdWUan Form was pmWdal by Rolland G. Haag wagY aft
demureness Furgral Cam, line
xaw
4W MVW Ay. Saratoga Spdtg0 NY 130116
and is Nared by Me laneml diRCNrpxipm9 Wib eaecubon �an
I/An him raga eda cwnpleWa may,of may AuefwNaal perm.
The wnonp)managed ralrvx blam She pareoMOMn mMol of disposal who by sie nine this AuMorhedan Front,B 9s)
W Ne accuracy and mmplB m W The Informal assumed In this Auawrhatlon Form and BUNml0ely)the fmpolne,
Slane this Sm day of Mt9um M Wn
Award P. Fidel Medal D
V+ 7
a8e Gwent IioM, BelleWn SpO, NV 1410
All
yu."al Ali
'MlNE88: wHu ww a++mm�
XOMerd G.
11638
wbdy9w s'n water news
WS1894f(Rev. M/LO) Phil