Guzek, Thomas J Pine View Cemetery & CrematOrium
Quaker Hoad
Queensbury, NY 12804
(518) 745-4477 Or (518) 745-4476
FUNERAL HOME: �y�
. .--..__.__PNNTJtO"'fIL _._ ... RETURN TIME:
DATE B TIME REMgINS gRRIVEO AT LRCmgY VRY. "
NAME OF FUNERAL DIRECTOR OR pECRISTERED RESIDENT DELIVERING REMAINS.
NAME. --" -
TYPE OF OF CONTAINER-
PLACE
(_�._ �N Gt GLV( •IYI✓`W Yv�PI^i I^i.OF DEATH TI MgPacP " Ar.T H.UpDl�T
... lT•F. _.._. Yrv`
ESTIMATED WEIGHT OF REMAINS y CONTAINER 1
PLACED IN Nolo
. __...
PLACED IN REFRIGERATION.
DATE OF ceemgnoN,
TIME STARTED: -_ CrIDD ,(JJy/_ TIME c /Z-y
PLACED IN RETORT O "�—
,iiz sAt. _movFD
RETORT II IN WrylCry REMAINS WERE CIiEMATEO.
DETA
LED
FROM TIME
Or AC FORDS LAYIFREMAINS WEIIE CREMATED MORE THAN "
FROM TIME Of ACCEPTED DELIVERY: HAN 40 HOURS
NOTE
"ATMN LOGSHAA.L n[ RIFTIONLO :n IRL pEl?NANLNT FILE OF iRE CREmnv011y,
Delawlere suite
EW YORK pIVIS10Il of OIVISIONOF....E"I�'OF
Cemeteries
Tale ternNY 1on4ab le
Authorization for Cremation and Disposition
"is AU omWw Form must the may pieW and a lame War W eelMn of making fer cre eon.
Dab:MM020 Number fil
Cmmtl Name'. Pone Ylsw Crematory
Mdinem 21 pucker Read Quadracci, NY 128M per. (518) 745J477
CREMATION B AN IRREVERSIBLE AND FINAL PROCESS.
eremamn is carried out by Will Are remama of the eereas and me consumer holding Me remains into a cremation crammrxeert
May are medical m Intense hers and Rome. Tdr hxt and Um will InclmmW and Consume aysrything aauq bore and me ,
Which are all Ns will the Mn after cmnatlon.
Follomig cremation,Am crtmaary will take mawnabb efforts to rem eall of Me remains am other marenalhmm the ueme
Chamber, but aorta minimal dust and residue all @elybe 10 obbi The crematory All separate imtloemal aril Real mgnal from
be RmainSaMlhBlntidemal and krelgn material Yell be diwoman of as r uil by lax. Theaemateoremainswinbemechanically
pulvm Indsmallpies:ar MamaInmadesignalmnleimr«um. CmmaWmmaimgemmilyalepuNmM uMIno
amglsmgment M meogmuble as akelN l nssus.
OPENING OF THE CONTAINER
The mmticry may Only pion day mnbiner holding be un<mmal human rermsns In limited orcummanms, such as a mnhrm me
kenti ofe de seddatenwm NMnommnal laentlose iw mgbl ln(ureemplOy"n Ordamage MecmmaterypmpW If
human remains are dsllwW Ina conhlmria lch Is net suitable for namanon such as mmmonlal or rental"SMS me
mebryr r ns Ns olof bamoldIwas NfmnblMrWbreIllcdon Meattains. TirengagOfe
mnhlrrer or Natran¢!mor Iamaval of remairewill W WMudetl CBlere a wtlreu eMvell be done m pnwcY.vdN tlignty eM respect
1°ENTIFKATION OF DECEASE°
Nam of oermasd'. Thomas J. Guuk Maridl5iB4Y: DW
Las Known Mdrwa: 58 Manou Ave SWabga Spil NY 12W AS 001
PNw of Death as MSOn Ame Saralee Spmgre, MY 12W W 001
sex'. Ill F Age:82 DOB 06/20/1958 Dam of ma :e11222030 EOMa MQM 1600
DBWip4m M ms Ww=llner in Mich remains MA be dNivned. / i. a/t. r cGaJ/�� L-0/
Cardboard Box wWJ en Base /W V rJ.
glitil la"
OF OISP°SmON
fM t5)in amnd m5po on iry W 0.VE of Mw(a4oaugf
ant are be destroyed meat of the dema6etl daIgnal In a will or w nirgbungnl eieuned mrsuaM W Public
M taw Se 0301.
-0R-
have0klwwlege,Mat the deposed eumled a whmInenument pursuant to Public Health law Se dab Ora
III w L=ing dlreche a for her doted Ron of he or her remains arm ME are Me person(s) having prig ity under Public Heals law
Setlion 4201 and have to rpht W womeine uunadon of Me remains of the demasM. Mylour reladonshlp ad Me doom Is as
lollmin:
Thomas J. Guzek
DOS-18ge-f)Rev.NQO) PINE t of
Authorisation for Cremation and Disposition
(Irloe "MewbE w)
M roper 2 Color Sprouse Anne Caes4ty
1. Acelson clannaad in rearm punua0l to Public III lee,Secdm 4201(5),
2. 1M surviving p0u
L. The sur ivrg tlOmprk"Met
a. Arry 6urvinrg child enhm n deers of no or earn
6. Asurvrvingparent,
S. ASurviving submit Samoan years of age Or OMg;
6. Alawlully appointed gunion;
1. Any plson(sl eigm n"am sage IX dEev alined W Mae in the pb and Who iNare do sl in reaccul pb tee OenpsE'.
& A duly appointed fiduciary Of day cents.
6. A serve fraud Or reythe wM hasexxukd a Syrian ebbngm ormuem Or Pink Hi "A Seamn 0201D),
10. AdiielfisCel OMrer Ma mun[d sera pWlkddminiepebraponbdpumuantW"Un0]ah'SCcud PrvMnreP
iM. Any Wier pelsOn who is amrq an behalf 0l Me da sl and wM has exWred a widen sfaremeM punuenl to Pain HeBM
"I Seclion 4201
(I,rr1N/a�rfALL THREE a her KKb chirp)
c �In Mnb/afblm Metthe body of aide dep d does nth contain a battery.pamry Pal power ttlaLo mn l, ra "ant,
anW"Ha CeNce and Mrtany such meradels were remcvad aware"aresulgn aide AU umBtl Form. Fillumm�ove
th nor to canna0on nay moult In harm by bass cmmabry and OmnMry Prson�nel.
aMnn Met lheruchorm My,man gteen to ROIisM IS Hopp
regalding the removal of any delsconal propMy or other Mira M value which any church eigniig C&ox Or Say f IN no WMe
dechepd''iyMdS M preserve. Pine very,Chancery
is has msponmbk for this remoal 0f(gnorul lams hour Me anchor or Min the remain$of the deceased. Proclaimed lams xh In they,
Zdo or W%Me Mnadv An pa Mtoyed M Meomatlon o process and cannot be represent afarcrerea0on.
hereby authorize Pine Very Chancery
a.nm.m M.rsm.ir.a M.aro.a..a.
(IMINV
OPTIONAL)
Sam Mmby authores Me named amend director to provide for delivery to aad cremation by an a am
rMraary, If emed necessary In Ma opin don of Me fuMnl direaop m and a amend able arm scattered provide Me rct name addaddress of such alternate mnawy.
FMAL oI9 aMM
iM pmn NMhAd M mmive be raemaW nmelru of Me dromcM Min the oeme as.
Ni Cwnpa oMM Funeral Care
Adder. 402 Mssge Ache..Sassed Sgdrys. W 12Mb. Pere; (518)bM'apur
The Schram rwnep of cow Sol W dM1psod&by alowe.
�C—FCe N 70 fFmfC�
If for any lepm Me peen named 81 does net Wte ppapion of Me mma roman,
PIMUlnacmmmo IS 6uIMAmda piss pxsessbnof
the rearders to axuw G$npu$IONx FI WCBR, Ire py Mfwery
In person or by ngisered nab. Nvwh� Tlmlasj Gough
OOS 18MI(Rec. 0i Iwhnw and 2MS
Authorization for Cremation and Disposition
maro w y
IM14a undelalana that If" remalm are not alarmed Samn llodaya mownetial.
lanavcw Cramamry m ydYpweauw in
aoamwn
an iwm ae eeal manner, Sinn as by .mnna.
CREMLTON CONIAINERNRN
GONE cl tdMLid)
An um W Ca u¢N as a Senegal brtlm aemMd remains M1tl own purchamed M1gn
and in Mounted as games
Ii uMelsland mar ittlla an is my,wag m MN he antis.ue Wramame.ane]TMnal al normal may de,dead Mr dNMay.
Oumu mrM WrTB¢M. lMb uMer¢bM WrllM um6 WrtMMrcoMervti¢e prwidad
Ralm Crematory Mil rea¢tlw tlamW] mmanm In
a npld bmpmry Wntalner for Swiss, rxnawceh�
Rolland G. NOep avm�at
Autlra/h¢Ibn Farm way pOvge]Ey vAe
Commensal Furenl Gany Me
Sal Maple Ava SB e9 - 6 NY 12M
and Is y i by me funeral meal as mil mits Showmenr
IN4 have receNed a completed deny of MIS Ammorkatlon Form
The parl Identlrlad blax Iola n me Ransi lal In call of disposition,who 4 signing Sale Addhommi Farm,atlea4s)
b1Ne attuady and cmmploweas of Me IMwmallon canMlmd In Mle AutlN/U OR Form and auNorY Slew fmsgolrrg.
Slgrmd MN 23 agal MememEer m 20 I/�I
Anne.mmv Cassidy l
a ax
IS Mancon Ave hhvvxs,. reVe aFl L01
Raids
WITNESS:
Rolland G. IMy
v 11fi05 exaewaarwvl Rw•+
e.m TnmaJ.Gums
0OS 189af hill Oil PyB3 alg