Kowalski, Phyllis Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: j-`7-20 2-0 3/D
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
A9 e-
NAME: � y ► 1�� W vl5/G1 CASE
TYPE OF CONTAINER: I'V76nr J,�)C Leh�wi r�P
PLACE OF DEATH: 6d Inn L&
ESTIMATED WEIGHT OF REMAINS & CONTAINER
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION: s�g�
TIME STARTED: TIME COMPLETED:
PLACED IN RETORT: 2 3S MOVED:
RETORT # IN WHICH REMAINS WERE CREMATED: Few--&xyr
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.
� NW
New York State
PORK Division of Department of State
STATE OF DMSION OF CEMETERIES
OPPORTUNITY One Commerce Plaza
Cemeteries 99 Washington Avenue
Albany,NY 12231-0001
Telephone:(518)474.6226
www.dos.ny.gov
Authorization for Cremation and Disposition
This Authorization Form must be completed and signed priior to delivery of remains for cremation.
Date:_ ! 4 Number:
Crematory Name: Pi review Crematory
Address: Queensburv, New York Phone: 5/P?q J4/,q 7 7 T
CREMATION iS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation is carried out by placing the remains of the deceased and the container holding the remains into a cremation chamber where)
they are subjected to intense heat and flame. The heat and flame win incinerate and consume everything except bone and metal,
which are all that will be left after cremation.
Following cremation,the crematory will take reasonable efforts to remove all of the remains and other material from the cremation
chamber, but some minimal dust and residue will likely be left behind. The crematory will separate incidental and foreign material from
the remains and the incidental and foreign material will be disposed of as required by law. The cremated remains will be mechanically
pulverized into small pieces and placed into a designated contaKter or um. Cremated remains generally are pulverized until no
single fragment is recognizable as skeletal tissue. `
OPENING OF THE CONTAINER
The crematory may only open the container holding the un-cremated human remains in limited circumstances,such as to confirm the
identity of the deceased or to ensure that no material is enclosed which might lr4ure employees or damage the crematory property. If
human remains are delivered in a container which is not suitable for cremation such as ceremonial or rental casket the
crematory will require that the remains be moved into a suitable container before it accepts the remains. The opening of a
container or the transfer or removal of remains will be conducted before a witness and will be done in privacy,with dignity and respect.
IDENTIFICATION OF DECEASED
Name of Deceased: t-- t cl sJ StY'11 L .� / Marital Status:
Last Known Address:
Place of Death: L) S
Sex: ❑ill �rV Age: OO DOS, dt. Date of Death: `f �� Estimated Weight: W
Description of caskettcontainer in which remains will be delivered.
PERSON IN CONTROL.OF DISPOSITION
(Perscwt(-�)in control of disposition,jqjW ONE of the following)
-- --' I arrvWe are the designated agent of the deceased designated in a will or written instrument executed pursuant to Public
Health Law Section 4201.
-OR-
have no knowledge that the deceased executed a written instrument pursuant to Public Health Law Section 4201 or a
will containing directions for the disposition of his or her remains and Uwe are the personW having priority under Public Health Law
Section 4201 and have the right to authorize cremation of the remains of the deceased, ur relationship to the deceased is as
follows: ( l
4L %A c 3 K1
DOS-1898-f(Rev.04120) Page 1 of 3
.hut ization for Cremation and Disposition
(Insert from the list below)
Number Description:_
I. A person designated in writing pursuant to Public Health Law Section 4201(3);
2. The surviving spouse:
2a. The surviving domestic partner,
3. Any surviving child eighteen years of age or older,
4. A surviving parent;
S. A surviving sibling eighteen years of age or older;
6. A lawfully appointed guardian;
7. Any person(s)eighteen years of age or older entitled to share in the estate and who is/are closest in relationship to the deceased:
8. A duly appointed fiduciary of the estate;
9. A close friend or relative who has executed a written statement pursuant to Public Health Law Section 4201(7);
10. A chief fiscal officer of a county or a public administrator appointed pursuant to the Surrogate's Court Procedure Act;
10a. Any other pew who is acting on behalf of the deceased and who has executed a written statement pursuant to Public Health
Law Section 4201(7).
(/rill ALL THREE of the following)
le hereby affirm that the body of the deceased does not contain a battery,battery rY pack,power Dell, radioactive implant,
or radioactive device and that any such materials were removed prior to the execution of this Authorization Form. Failure to remove
these items prior to cremation may result in harm to the crematory and crematory personnel.
1 e affirm that instructions have been given to MaCkeri Mort.Uary
regarding the removal of any personal property or other thing of value which any person signing below or any family member of the
deceased wishes to preserve. Pineview Crematory
is not responsible for the removal of personal items from the container or from the Terrains of the deceased, personal items left in the
"ntainer or with the remains will be destroyed by the cremation process and cannot be retrieved after cremation.
lei--_J {ewe hereby authorize Pineview Crematory
(cry m—)
InitialOPTtONAL) to cremate the remains of the deceased.
�.,
Uwe hereby authorize the named funeral director to provide for delivery to and cremation by an alternate
crematory,If deemed necessary in the opinion of the funeral director,and to amend this form to provide the correct name and
address of such alternate crematory.
FINAL DISPOSITION
The person authorized to receive the cremated remains of the deceased from the crematory is:
Name: --�� 1 ��.� ►�� h r t:;
Address: 3 tfl`s tiz r< `�Q 1 V E (/a 7a S l b 7 4,4 � 3
Phone:
The cremated remains of deceased will be disposed of as follows:
- Return to family
If for any reason the person named above does not take possession of the cremated remains. T
Pineview Crematory is authorized to give possession of
the remains to Macken Moir' by delivery
{Funsrpf Horns Name)
in person or by registered mail.
{Nagle t/OucnasexlJ
DOS-1898-f(Rev.04/20) Page 2 of 3
AuthPrization for Cremation and Disposition
(Mar the foftwirrg)
I! a tmdersiand that if the remains are not claimed within 120 days of cremation,
Pi.rieview Crematory
„M of o may dispose of the remains in
an irretrievable manner,such as by scattering.
CREMATION CONTAINER/URN
(Mid 1NE of me tdlomng)
t An urn to be used as a container for the cremated remains has been purchased from
and is described as follows:
I/We understand that if the um is too small to hold the entire cremated remains,an additional rigid container may be used for delivery.
/ -OR-
An um is not yet purchased. l/We understand that if no um is purchased or otherwise provided
Pineview Crematory will place the cremated remains in
04w"orcwnworo
a rigid temporary container for delivery.
This Authorization Form was provided by Joseph R. Noll was executed at
ffWn-W D#omr Morns}
Murmnf Fbna►Msmsl
52 Clinton Avenue Rockville Centre NY 11570
r + .Ate)
and is signed by the funeral director as witness to its execution.
I/We have received a completed copy of this Authorization Form.
The person(s)identified below islars tile person(s)in control of disposition,who by signing this Authod ketion Form,attests)
to the accuracy aq j completeness of the information contained In this Aut tor&edon Form and authoHze(e)the foregoing.
Signed this t'j day of .20 c�C3
Q'V�T�it l — -MA MA IJT R NCI ---
Typed or PMW Mare
S -5 w� h �, t7 O1
nydresa .'
Ak bra m&+naval
T o< nnMd Mw w
ryysd Or PM*Dd M ,g
ad&e"
ti
wlT�less:
Joseph R. Noll ��-
(FwwrW Doodor Typed or Pnnw Nss*) !F D�safor )
rnaprarraavrt naenoer) 12664
DOS-18984(Rev.04120) Page 3 of 3
2950 DEPARTMENT OF HEALTH
REGISTER NUMBER CERTIFICATE OF DEATH
' ..1 STATE FILE NUMBER
i. AME:FIRST MIDDLE LAST 2.SEX: 3A.DATE OF DEATH: 1 38.HOUR:
MALE FEMALE MONTH DAY YEAR
Ph Ilis Kowalski ❑1 ®2 OS 04 2020 03:00 PM
4A.PLACE OF DEATH: HOSPITAL HOSPITAL HOSPITAL NURSING PRIVATE HOSPICE OTHER
14B.IF FACILITY,DATE ADMITTED: DAY YEAR
(Check one) DOA ER OUTPATIENT INPATIENT HOME RESIDENCE FACILITY (Speci):
❑ ❑ ❑ ® ❑ ❑ ❑ ❑ 1 04 25 2020
4C.NAME OF FACILITY:(II not facility,give address) 4D.LOCALITY:(Check one and specify) 14E.COUNTY OF DEATH:
Mount Sinai South Nassau I CITY VILLAGE TOWN
❑ ❑ ❑ Hempstead Town 1 Nassau
4F.MEDICAL RECORD NO. G.WAS DECEDENT TRANSFERRED FROM ANOTHER INSTITUTION?(If yes,specify institution name,city or fawn,county and state)
620509 I ElNO Y® BRISTAL LYNBROOK SENIOR CARE,Lynbrook, Nassau,New York
5.DATE OF BIRTH: 1.AGE IN 6B.IF UNDER 1 YEAR 6C.IF UNDER 1 DAY 7A.CITY AND STATE OF BIRTH:(IfnotUSA,Countryand 7B.IF AGE UNDER 1 YEAR,NAME OF HOSPITAL OF
MONTH DAY YEAR YEARS: I ENTER: I ENTER: I Region/Province) I BIRTH:
� 86 months days -I--hours minutes I
12 1 27 1933 I I I I I I
.0 N yrs. I I I Brookl n Borough,New York
S.SERVED INU.S.ARMED 9.DECEDENT OFHISPANICORIGIN'?ChecktheboxestnatbestoescnbewhemermedecedentisSpanishaspanwLahho. 10.DECEDENT'SRACE:Checkorreormoreracestoindicatewhatthedecedentwnsideredhimsellcrherselltobe:
i+ FORCES?(Specifyyears)
NO YES A®No,not Spanish/Hispanic/Latino B❑Yes,Mexican,Mexican American,Chicano A®White/Caucasian 8❑Black or African American c❑Asian Indian D❑Chinese
00.0
(n ®O ❑1 C❑Yes,Puerto Rican D❑Yes,Cuban
�(/� E❑Filipino F❑Japanese G❑Korean H❑Vietnamese
r E❑Yes,Other Spanish/Hispanic/Latino(Specify)
_ 11.DECEDENT'S EDUCATION:Checkbreboxthatoestdescribes the highestdegreeoriewlofschoolcompletedatdrenmeotdulb. J❑Native Hawaiian K❑Guamanian orChamorro M❑Samoan
1❑s 8th grade 2❑9th-12th grade;no diploma 3 m High school graduate or GED N❑American Indian or Alaska Native(specify)
a ) O 4❑Some college credit,but no degree 5❑Associate's degree 6❑Bachelor's degree P ElOther Asian(specity) R❑Other Pacific Islander(specify)
I M L. 7 ElMaster's degree 8 ElODLtorate/Protesslonal degree S❑Other(specify)
t L 12.SOCIAL SECURITY NUMBER: 13.MARITAL STATUS: 14.SURVIVING SPOUSE:
�+ 0 NEVER MARRIED MARRIED WIDOWED DIVORCED SEPARATED Enter birth name of spouse
123-26-7955 ❑t ❑2 ❑3 ®4 ❑5 it married or separated.
N15A.USUAL OCCUPATION:(Do not enter retired) 1 15B.KIND OF BUSINESS OR INDUSTRY: 115C.NAME AND LOCALITY OF COMPANY OR FIRM:
I Clerical worker I Office
16A.RESIDENCE: Coun or Re
(State or Country fnotUSA: gIon/Province i6C.LOCALITY:(Check one and speciy) Ii6FIFCITYORVILLAGE,ISRESIDENCE
ifnotUSA) CITY VILLAGE TOWN WITHIN CITY OR VILLAGE LIMITS?
16B.
NY Nassau ❑ El Lynbrook Village I DYES DNo IF NO,SPEC IFYTOWN:
16D.STREET AND NUMBER OF RESIDENCE: 116E.ZIP CODE:
8 Feer Street I
111563
17.BIRTH NAME OF FIRST MI LAST 18.BIRTH NAME OF FIRST MI LAST
FATHER/PARENT: MOTHER/PARENT:
Frank Gelista Gilda lacovino
19A.NAME OF IN
119B.MAILING ADDRESS:(include zip code)
Catherine Tramantano 1383 Woodbridge Road,Rockville Centre Village,NY 11570
20A.1❑BURIAL 2XCREMATION 30REMOVAL 40HOLD 50DONATION 1 208.PLACE OF BURIAL,CREMATION,REMOVAL OR OTHER DISPOSITION. 20C.LOCATION: C or town and state MONTH DAY YEAR I (City )
6❑ENTOMBMENT 05 07 2020 I Pineview Cremato
• rY 1 Queensbury Hamlet,New York
21A.NAME AND ADDRESS OF FUNERAL HOME: Macken Mortuary Inc 21B.REGISTRATION NUMBER:
52 Clinton Avenue,Rockville Centre Village,NY 11570 101089
22A.NAME OF FUNERAL DIRECTOR: 122B.SIGNATURE OF FUNERAL DIRECTOR: 1 22C.REGISTRATION NUMBER:
1�
23A.SIGNATURE OF REGISTRAR: 23B.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 AI Signature:
lonathanACtus,9I4rD Month Da Year
Jonathan Altus,MD 164913 ► rECectronicaff S'ned 05 05 2020
Certifier's Title: 0®Attending Physician 0❑Physician acting on behalf of Attending Physician Address:
1❑Coroner 2❑Medical Examiner/Deputy Medical Examiner 1 Healthy Way,Hempstead Town,NY 11572
258.If coroner is not a physician,enter Coroner's Physician's name 6 title: License No.: Signature: Month Da Year
►
25C.If certdier is not attending physician,enter Attending Physician's name 8 little: License No.: Address:
26A.Attending physician Month Da Year Month Da Year 26B.Deceased last seen alive Month Da Year 26C.Prounounced Month Da Year Time
attended deceased: FROM 04 27 2020 TO 05 04 2020 by attending physician: 05 04 2020 °P° ON 05 04 2020 AT 03:00 PM
2 MANNER OF 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 I CAUSE OF DEATH?
®1 02 03 ❑4 El ❑6 0®NO 10YES 930 ❑1 02 I 0❑NO 1❑YES
CONFIDENTIAL SEE INSTRUCTION SHEET FOR COMPLETING CAUSE OF DEATH CONFIDENTIAL
gd 30.DEATH WAS CAUSED BY:(ENTER ONLY ONE CAUSE PER LINE FOR(A),(B),AND(C).) APPROXIMATE INTERVAL
BETWEEN ONSET AND DEATH
I
T I.IMMEDIATE CAUSE:acute res irato distress s ndrome 19 days
TO OR AS A CONSEQUENCE OF: I
pneumonia19 days
TO OR AS A CONSEQUENCE OF: 1COWID-19 19 days
T 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
.IF INJURY,DATE: i HOUR: 1 31B.INJURYLOCALITY:(City or town and county and state) 31C.DESCRIBE HOW INJURY OCCURRED: 31D.PLACE OF INJURY: 31E.INJURY AT WORK?
TH DAY YEAR NO YES
1 ❑0 ❑1
IF TRANSPORTATION INJURY,SPECIFY: 32.WAS DECEDENT31IFFEMALE: 33B.DATE OF DELIVERY D...lopernor 2❑Passenger 3❑Pedestrian HOSPITALIZED IN NO YES °®Not pregnant within last year 1❑Pregnant at lime of death 2❑Not pregnant,but pregnant within 42 days of death MONTH DAY YEAR