Rehak, Stephen Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: c;ckag,, � s/fi2�;�� _ RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: _ 7-24Zra "�ifj�h'►
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
Jo e- A),) P
NAME: M 2a- CASE # SS�f
TYPE OF CONTAINER: , �,k,'nL„�LG
PLACE OF DEATH: yl Z(,� '►,ti}I�m r p L� ti � ,� /jSS ��
ESTIMATED WEIGHT OF REMAINS & CONTAINER_ Zc)"4 14 c-,lid 23
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION:
TIME STARTED: _ 3. 3 `'h TIME COMPLETED:
PLACED IN RETORT: MOVED: jo en
RETORT # IN WHICH REMAINS WERE CREMATED:
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SHALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
New Y(gk Steer
NEWYORKIE I Wsion of Department of state
STAT Of DPMRM OF CEA4MRW-S
OPP NI
ORTUTY, 06-W Commerce Pram,Lql` Cemeteries99 VV*Stungton A,—r,.s,,
Aff.),iny NY 72131 E"ov
Ttiepharw- 15%)47462.6
Authorization for Cremation and Disposition www d0i rvv 90V
This Authorization Form must be cOnWkftd and Signed Prior to delivery of remains for cremation.
Date PAR
Number--.—
Nx-ne crew
Addte-.- New,York Phone._ '7,1/
CREMATION IS AN IRREVERSIBLE AND FM AL PROCESS.
Cremation is UWM('L-l"t t)y V14(-,k(19 the remains of We deceased and ft contairier ho"the remains into a cremation Chamber where
lh&Y are,sub)ectod In intense neat and name. The heat and Raw win incin"Me and consume everything except bone and no,*,,
which are oil that will be left after cremation.
Follow,nig cremation the Cfe%Mory will take reasonable efforts 10 remove 80 Of the remains and other matenal from the cremation
cliam.ot•r,but sorne Mn'(11.3i 0,;s'and resxkw writ 14"be left behind�
the rerijift and"* The Crematory will separate incidental and foreign material tmr"
r,'Cbde';tzsf and foreigri material will bedWVo"do(asr8qL*,sd try law. The crematedy
pulverized into srnall Pieces it'd PlaCed into a do$g%aftd container or urn. Cremated remains remains will be mocharica
single fragment is recognizable as skeletal this", gwm"lly at*puN*dzod until no
za
OPENING OF TtiE CONTAINER
The crematory may only open tree container hOktng the urn-CTOM010d human remains in Irmited circumstances,such as to confirm the
identity of the deceased or to ensure that AO material is enclosed vituch might 0*"empkiyeas or damage the crematory property It
human remains are delivered in a container which is not sun"for cremation such as ceremonial or rental casket the
crematory will require that the remains be moved into a suitable container befor
e it accepts the remains. The opening of a
oontainc-r of the trarster cx remcval of remains will be conducted before a witnew and will be done in pr,vacy, with dignity and respect
IDENT fjg^,T�_I _QF Og LASE0
Name of Deceased
Mantal Status
Last Known Address W T m lysr I I i"j-
Place or death-, 1�-'
S11 93 M OF A,;r 6. 008, Date of Death. S
Descnpt on of casKelcontainer,i which remains vAll be delivered.
L I M?4 00
PERSON IN CONTROL OF DiSPOSMN
p rontrol of �q�/ONE of Me WoieiV
Z amMe afe tt+e orsignated agent of the deceased desl9ruft(I in 8 will Or written otstiument executed pursuant to Raw
Heeditt L-4W Section 4 2c,I
104R- Me)save o t ru.1-4-tage that the deceased executed a wrMen instrurnent pursuant to Public Health Law Section 4201 or a
uo -on aning directions tw ttwd,sposibon of his or her remains and Wm are the person(s)having pnority,order Public Health Law
Se,A un 4201 and hive tt-w authonze cremmon Of the r4MMM of the doceasW. ARYIOur relationship to the deceased is as
follows
v If Air
Page 1(313
Authorization for Cremation and Disposition
fry M IN*
Numtw�
1. Person t*%";tnat 'I�-
I 1j1%0-
"I wfil"pursuant to PUbhC#*SNh Law Section 4201(3�,
,IWS6WVFV1Mj 1'rx
Za. The sumv;nq(jorr-j-SIK:varjnCF,
eighteen years of age oroidor,
'A SWVNjnq g)aren*,
5. A SUrNwing v!-Ultleen years of age or older;
6. A LWURY
7. Any persoN S j "W or older enliftd to share in lhe estate and who Ware closest relationship to L deceased
A duly appopmer fi�'OC,Ory W the estate_9.
the
A Close Trwncl or relative who has executed a written statement
A ctw*ftsrW<jjfWe!,�f a va�lrjv 1w a public administrator appoirrPUISUIN't 10 Public Health Low Section 4201(7);
118S, ArrV Other pef5,0t, �rra 'ad S t to the Suffogate' -ou"
trf+ram on pur usn s C Procedure AC1.
i,3w SOCItor,4.'() , behalf 01'the dacceased and who hn executed a wrrnen statemery(pursuant to Public 1-4ealtt,
�J1,_„r+tlt:'e
ALA THREE of the#j qow;rjq)
hcwtiy jn,j�j the body Of the deceased does not contain a battery.battery PaCk,power cell.radioactive imolant
Or MJOWU"Clewce and i"I any such rnaftlials were removed prior 10 ft exaCtttiOn
Of MM Authorization Form. Failure to remove
an Prior to Cremation may result In harm to am crematory WW Crematory pmonnel_
VWe affirm tha:tristructtons have been given to_.. Macken Mortuan
regarding Me remove!Of any personal property of other"of
v"M which any Person wMkV below Of any family member of the
deceased wishes to Preserve 2�to1
is not responsible for the ra rri,)va!of oersonal dens from the contWW xMWW-4"*Or from the remains Of the deceased. Personal items left in the
containor or with the remains will be destroyed by the cremstim Process and cannot be retrieved atter cremation
YWO hereby authorize Pineview Cramwry
to Cremate,the rwmains,of the deceased
tfwe hereby authhorize tits narrhed turherai director to Provide for d*WAwy to MW cremationry,it deemed necessary in the opinion of the hahtni dlractor,anti by an alternate
address of such sitemate crematory. to amend this form to Provitis,the correct name and
FWAL DISPOsITION
The Person authorized to recolve ft cremated remains Of the deceased from the crematory is.
Name� iv-
-ANVV�
A.I. qrv" so?
40
r-�Lp— — —
The cren'-'AW remains of Deceased will be disposed of as follows,
ecurn to family
If for any reason the pertwvi+kamed above does riot take Possession of the cremated femarns,
;,;-j-eV.ieW cram wry
is auftsized to give Pos—s-s—of
the rerruj M, to Macken Mortuary
by dellvpry
tFw*qw 'm xvnrw
in pemrn or by >r4 A-
OS-1898-f(Rev.04 20) Page 2 of 3
Ai= lorization for Cremation and Disposition
e unetrrstarui That it the ronwww are►of ctaimed y.*m 120 days of CMIMlion.
,. ......,,.�........._..._.�_ ,...._..___--, may depose of Me r*rnwm In
,ovaWe manner,such as tl
Titalt Ct�tiTAls+matireu
Of the t` *v)
M um to be used as S Contamer for go Cremated remains his been PumhaW from
ano deSCrbed as k*ovvs.
W ;'-tSAWW that d the um is too sm"to hold the erexe tronaW remains,an addkiortst rind corttareter mey be used for delivery
-C
WkC11n um rs not yet Purchased. lNMe tuxierstwW OW if no um is purchased or otherwise provided
__. P2,fCAM O W C> to7t WO PI8cc the Cremated renum m
a ri pOrary CO"tamer for delivery
Tt. .,,orfzatton Form was Wovoded by Joseph R. Noll
was execuoed at
__..t'la�duert F3art'a�saxy
Rockville Centre NY 11570
ed by the tuts rail direcfw as wow=M its WAWU M _.. .. _,
received a comPWW copy of this Audrad:atlon Foam.
T t cons)identified below Wme#W person(s)in canna of dispoNtiort,who by SIPW g Oft Au#wdSaftn FQnm,�Ks)
to V acy �p+etenese of the kWon mgm cOntsined in Oft Aulborflr e an
on Fonw d;�rf�{e)u+e
Sign. t chic day of .28,x, _-
_ ter. er
"C, IZ Sit?'? At I/
wir
L R- Noll
oc> '(Re oa s O! QaQe 3 of 3
t
`ZFULJ DEPARTMENT OF HEALTH
REGISTER NUMBER CERTIFICATE OF DEATH �'DAi
1.NAME:FIRST MIDDLE LASTSTATE FILE NUMBER
2.SEX: 3B.HOUR:
Ste hen Rehak MALE FEMALE MONTH AY Y
4A.PLACE OF DEATH: HOSPITAL HOSPITAL HOSPITAL NURSING PRIVATE HOSPICE OTHER ®1 ❑2 05 01 2020 06:00 PM
1 (Checkonel DOA ER OUTPATIENT INPATIENT HOME RESIDENCE FACILITY (Specify): 148.IFFACILfTY,DATEAOMITTED: DAY YEAR
El z
4L.NAME OF FACILITY:(fl not facility,give address) 4D.LOCALITY:(CheCkone and specify)
I CITY VILLAGE TOWN 426 Autumn Drive,East Meadow I (4E.COUNIY OF DEATH:
p El Hempstead Town I Nassau
4F.MEDICAL RECORD N0. 4G.WAS DECEDENT TRANSFERRED FROM ANOTHER INSTITUTION?(Ifyes,specify institution name,city ortown,counlyand state)
1 NO YES
J 1 ® ❑
r 5.DATE OF BIRTH: 6A.AGE IN 68.IF UNDER 1 YEAA 6C.IF UNDER 1 DAY 7A.CITY AND STATE OF BIRTH:(Ilnot USA,Country and 78.IFAGE UNDER 1 BIRTH:
YEAR.NAME OF HOSPITAL OF
(� MONTH DAY YEAR
YEARS: 1 ENTER: I ENTER: I Region/ProVince) I_ � � months days I hours minutes I
a 02 09 1953 67 7 yrs.
I Flushin Hamlet, New York 8 SERVED IN U.S.ARMED 9.DECEDENTOF HISPANIC ORIGIN?Checkthe Dom that bestdescnoewnenermedeueentsSWnshMi FORCES?(Specifyyears) sPanN.anno 10.DECEDENTS RACE:CtArkanewmare razes indiate what the OecMent consideredhimsedwherse/ftd be
NO YES A®No,not SpanisNHispanic/Latmo B ElYes,Mexican.Mexican American,Chicano
®O El1 A®WhhelCaucasian 8❑Bo tock or African American C❑Asian Indian D❑Chinese
y •y � C❑Yes,Puerto Rican 0 El Yes,Cuban
r E❑Filipino F❑Japanese G❑Korean H❑Vietnamese
0 _ r . E❑Yes.Other Spanistul ispanic/tatino(Specify)
11.DECEDENT'SEDUCATION:ChecktheboxmatbestdeuhbestA!A nest J❑Native Hawaiian K❑Guamanian orChamorro ME]Samoan
W depreewkrNo/uhoolcompAlfedat the dmealdeam.
> 1❑s 8th grade 2❑9th-12th grade;no diploma 3®High school graduate or GED N❑American Indian or Alaska Native(specify)
Vr ) 0 4❑Some college credit.but no degree 5❑Associate's degree 6❑Bachelor's degree
N P El Other Asian(specify) R❑Other Pacific Islander(specify)
1❑Master's degree 8❑Doctorate/Professional degree S❑Other/specify)
t L 12.SOCIAL SECURITY NUMBER: 13.MARITAL STATUS: 14.SURVIVING SPOUSE:
N Ni..e NEVER MARRIED MARRIED WIDOWED DIVORCED SEPARATED Enter birth name of spouse
116-38-7693 131 ❑2 ❑3 ®4 ❑5 if marred or separated.
N 15A.USUAL OCCUPATION:(Do notenterretired) 158.KING OF BUSINESS OR INDUSTRY:
Administration i 15C.NAME AND LOCALITY OF COMPANY OR FIRM.
Tobacco Company I Lorillard Tobacco Com an ,New York,New
16A.RESIDENCE: 168.County or Region/Province
(State or USA)Country if not USA: 16C.LOCALITY:(Check one and specityl 16F IF CITY OR VILLAGE,IS RESIDENCE
loot USA) NY CITY VILLAGE TOWN ONES
CITY OOR VI F AGE LIMITS?
IMI S?TOWN:
Nassau ❑ ❑ ❑ East Meadow Hamlet I 16D.STREET AND NUMBER OF RESIDENCE:
426 Autumn Drive 116E.ZIP CODE: 1
17.BIRTH NAME OF FIRST MI LAST 111554 I
FATHER/PARENT: 18.BIRTH NAME OF FIRST MI LAST
MOTHER/PARENT:
Martin Rehak Katherine Peknik
19A.NAME OF INFORMANT: 119B.MAILING ADDRESS:(include zip code)
Michael Rehak 12479 Westlake Drive,Oceanside Hamlet,NY 11572
2OA.1❑BURIAL 2 CREMATION 3❑REMOVAL 4❑HOLD 5❑DONATION 1208.PLACE OF BURIAL,CREMATION,REMOVAL OR OTHER DISPOSITION. 20C.LOCATION: C or town and state
6❑ENTOMBMENT MONTH DAY YEAR I (Iffy )
05 1 06 2020 I Pineview Crematory 1 Queensbury Hamlet,New York
21A.NAME AND ADDRESS OF FUNERAL HOME: Macken Mortuary Inc 1 21B.REGISTRATION NUMBER
52 Clinton Avenue, Rockville Centre Village,NY 11570 101089
22A.NAME OF FUNERAL DIRECTOR: 122B.SIGNATURE OF FUNERAL DIRECTOR: i 22C.REGISTRATION NUMBER:
11 I
23A.SIGNATURE OF REGISTRAR: 238.DATE FILED: 24A.BURIAL OR REMOVAL PERMIT ISSUED BY: 24B.DATE ISSUED
MONTH DAY YEAR MONTH DAY YEAR
ITEMS 25 THRU 33 COMPLETED BY CERTIFYING PHYSICIAN--OR--CORONER/CORONER'S PHYSICIAN OR MEDICAL EXAMINER
25A.CERTIFICATION: To the best of my knowledge,death occurred at the time,date and place and due to the causes stated.
Certifier's Name: License No.: Signature:
Tamara Bloom,MD Month Da Year
Tamara Bloom,MD 161068-1 ► Electronicaff S'ned 05 02 2020
Certifier's Title: 0❑Attending Physician 0❑Physician acting on behalf of Attending Physician Address:
1❑Coroner 2®Medical Examiner/Deputy Medical Examiner 2251 Hempstead Tpke,East Meadow, NY 11501
258.N C
roner is not a physician,enter Coroner's Physician's name 8 title: License No: Signature: Month Da year
25C.N rtrfier is not attending physician,enter Attending Physician's name a title: License No.: Address:
26A.Attending physician Month Da Year Month Da near
D-
a deceased: 268.Deceased Ast seen alive M� Day v far 28C.Praunounced Month D v Time
FROM Tg byattendingphysician: Dead oN 05 01 2020 AT 06:00 PM
27.MANNER US DEATH: UNDETERMINED PENDING 28.WAS CASE REFERRED TO 29A.AUTOPSY? 298.IF YES,WERE FINDINGS USED TO DETERMINE
NATURAL CAUSE ACCIDENT HOMICIDE SUICIDE CIRCUMSTANCES INVESTIGATION CORONER OR MEDICAL EXAMINER? NO YES REFUSED 1 CAUSE OF DEATH?
®1 ❑2 ❑3 ❑4 ❑5 ❑6 0❑NO 1®YES ®0 ❑1 ❑2 1 0❑NO 1❑YES
CONFIDENTIAL SEE INSTRUCTION SHEET FOR COMPLETING CAUSE OF DEATH CONFIDENTIAL
130.DEATH WAS CAUSED BY:(ENTER ONLY ONE CAUSE PER LINE FOR(A),(B),AND(C).) APPROXIMATE INTERVAL
PART I.IMMEDIATE CAUSE:
BETWEEN ONSET AND DEATH
(A)Con estive heart failure I Unknown
DUE TO OR AS A CONSEQUENCE OF:
1
- (B)Arteriosclerotic cardiovascular disease I Unknown
_ DUE TO OR AS A CONSEQUENCE OF:
(C)<<<>>> I
<<<>>>
PART II.OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO DID TOBACCO USE CONTRIBUTE TO DEATH?
DEATH BUT NOT RELATED TO CAUSE GIVEN IN PART I(A) <<<»>
0❑NO 1❑YES 2❑PROBABLY 3®UNKNOWN
31A.IF INJURY,DATE: i HOUR: i 31B.INJURY LOCALITY.(City or town and county and state) 1 31C.DESCRIBE HOW INJURY OCCURRED: 1 31 D.PLACE OF INJURY: 31E.INJURY AT WORK?
ONTH DAY YEAR
M
I 1 i NO YES
❑0 ❑1
31 E IF TRANSPORTATION INJURY,SPECIFY: 32.WAS DECEDENT 33A.IF FEMALE: 338.DATE OF DELIVERY:
1❑D,"r/Operata 2❑Pusmger 3❑Pedestrian H�OSPITMnIZED IN NO YES 0❑Not pregnant within last year 10 Pregnant at rime of death 2 Not pregnant,but prepram within 42 Days of deem MONTH DAY YEAR
❑