Lozada, Dahlia S2� (
Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: Mak", U(�� RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY:
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
NAME: CASE # �ZJ
TYPE OF CONTAINER: Co 66A C-n
PLACE OF DEATH: �k I h Gt l
ESTIMATED WEIGHT OF REMAINS & CONTAINER_ I'lb ,:)
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION: J " 5 -20 2D
TIME STARTED: ,p -5 I /1-1 TIME COMPLETED: U �G'O �/ r✓1
PLACED IN RETORT: 'ZJ J��Ji"'1 MOVED: /3�rJI'�'1
RETORT # IN WHICH REMAINS WERE CREMATED: ?6we-/ �L
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 York State
Department of State
NEW YORK D�VISIOR Of DIVISION OF CEMETERIES
STATE OF One Commerce Plaza
QPPORTUNITY_ 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 prior to delivery of remains for cremation.
Date: May 3, 2020 Number:
Crematory Name: Pineview Crematory �j Z
Address: 4ueensbury, New York Phone: 51 e
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 will 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 container or urn. 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 injure 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: Dahlia Lozada Marital Status: Never married
Last Known Address: 1441 Gateway Boulevard, Far Rockaway, NY 11691
Place of Death: Mount Sinai South Nassau _—
Sex: 13 M [aF Age: 73 DOB: 05/02/46 Date of Death: 04/16/20 Estimated Weight: 7aS
Description of casket/container in which remains will be delivered.
Alternate container
PERSON IN CONTROL OF DISPOSITION
(Pers n(s)in control of disposition, initial ONE of the following)
tom►
I am/We are the designated agent of the deceased designated in a will or written instrument executed pursuant to Public
Health aw Section 4201.
R-
I/We have no knowledge that the deceased executed a written instrument pursuant to Public Health Law Section 4201 or a
wil ntaining directions for the disposition of his or her remains and I/we are the person(s)having priority under Public Health Law
Section 4201 and have the right to authorize cremation of the remains of the deceased. My/Our relationship to the deceased is as
follows:
Dahlia Lozada
(Name of Deceased)
DOS-1898-f(Rev.04/20) Page 1 of 3
Authorization for Cremation and Disposition
(Insert from the list below)
Number: 5 Description: sister
1. 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;
5. 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 person who is acting on behalf of the deceased and who has executed a written statement pursuant to Public Health
I Law Section 4201(7).
iti 1 ALL THREE of the following)
I/We hereby affirm that the body of the deceased does not contain a battery, battery pack, power cell, radioactive implant,
or radioactive device and that any such materials were removed prior to the execution of this Authorization Form. Failure to remove
teems, prior to cremation may result in harm to the crematory and crematory personnel.
I/We affirm that instructions have been given to Macken Mortuary
(Funeral Director Name)
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
(Crematory Name)
is not responsible for the removal of personal items from the container or from the remains of the deceased. Personal items left in the
t finer or with the remains will be destroyed by the cremation process and cannot be retrieved after cremation.
I/V1le hereby authorize Pinevi.eW Crematory
(Crematory Name)
to cremate the remains of the deceased.
(1 ' - PTIONAL)
Uwe hereby authorize the named funeral director to provide for delivery to and cremation by an alternate
cre ory,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: Ina McDarby
Address:
5 Worten Phone:dyke Road, Park Ridge, NJ 07656 201-391-7047
The cremated remains of deceased will be disposed of as follows:
Returned to family
If for any reason the person named above does not take possession of the cremated remains,
Pineview Crematory is authorized to give possession of
(Crematory Name)
the remains to Macken Mprtua-ty by delivery
(Funeral Home Name)
in person or by registered mail. Dahlia Lozada
(Name of Deceased)
DOS-1898-f(Rev.04/20) Page 2 of 3
Authorization for Cremation and Disposition
(Ini'al the following)
C
I/We understand that if the remains are not claimed within 120 days of cremation,
Pineview Crematory may dispose of the remains in
(Name of Crematory)
an irretrievable manner, such as by scattering.
CREMATION CONTAINER/URN
(Initi 1 ONE of the following)
An urn to be used as a container for the cremated remains has been purchased from
and is described as follows:
INVe understand that if the urn is too small to hold the entire cremated remains, an additional rigid container may be used for delivery.
An urn is not yet purchased. I/We understand that if no urn is purchased or otherwise provided
Pineview Crematory will place the cremated remains in
(Name of Crematory)
a rigid temporary container for delivery.
Macken NYJrtuary
This Authorization Form was provided by was executed at
(Funeral Director Name)
Mackeri Mortuary
(Funeral Home Name)
3930 Long Beach Road, Island Park, NY 11558 Internet
(Funeral Home Address)
and is signed by the funeral director as witness to its execution.
INVe have received a completed copy of this Authorization Form.
The person(s)identified below is/are the person(s) in control of disposition,who by signing this Authorization Form,attest(s)
to the accuracy and completeness of the information contained in this Authorization Form and authorize(s)the foregoing.
Signed this 3rd day of May .20 2020
Irma McDarby
Typed or Printed Name Signature
5 Wortendyke Rd, Park Ridge, NJ 07656
Address
Typed or Printed Name Signature
Address
Typed or Printed Name Signature
Address
WITNESS:
(Funeral Director yped or Printed Na1me (F erel Directo Signature)
(Registratio b r
Dahlia LOZada
(Name of Deceased)
DOS-1898-f(Rev.04/20) Page 3 of 3
r
PUBLIC HEALTH LAW
§ 4145• Deaths; burial and removal permits; disposition of remains. 1. No person in charge of any premises on which
interments, cremations or other disposition of the body of a deceased person are made shall inter or permit the
interment or other disposition of any body unless it is accompanied by a burial,cremation or transit permit,as provided
in this article.
2. (a) The funeral director or undertaker shall deliver the burial permit to the person in charge of the place of burial or
other disposition before interring or otherwise disposing of the body or shall attach the removal or transit permit to the
box containing the body,when shipped by any transportation company,which permit shall accompany the remains to its
destination, where, if within this state, it shall be delivered to the person in charge of the place of burial or other
disposition.
(b)Any person or other entity owning,operating,managing,or designated to receive the body of a deceased person at a
place of burial, cremation, or other final disposition in this state, who receives the body of a deceased person, shall
provide a receipt for the body to the funeral director, undertaker or registered resident who delivered such body. Each
receipt shall(i) be endorsed by both such person and the funeral director, undertaker or registered resident,(ii) indicate
the date the body was delivered, (iii) include the name of the funeral director, undertaker or registered resident
delivering the body and the registration number of such funeral director, undertaker or registered resident, (iv) include
the name of the registered funeral firm the funeral director,undertaker or registered resident represents, (v) include the
name of the deceased person as it appears on the burial, cremation, or transit permit, and (vi) include the name of the
owner, operator, manager, or person in charge of the place of burial, cremation, or other final disposition who received
the body of the deceased person.A copy of such receipt shall be retained by the owner,operator, manager, or person in
charge of the place of burial, cremation, or other final disposition for a period of not less than four years, and shall be
made available for inspection by the division of cemeteries during normal business hours.The original copy of every such
receipt shall be retained by the licensed funeral firm for a period of not less than four years pursuant to the rules and
regulations of the department governing the maintenance of records.
3.The person in charge of the place of burial or other disposition shall endorse upon the permit,the date of interment,
or cremation or other disposition over his signature, and shall return all permits so endorsed to the registrar of his
district within seven days after the date of interment,cremation or other disposition.
4. When burying or otherwise disposing of the body of a deceased person in a cemetery or burial place having no
person in charge,the funeral director or undertaker shall(a) sign the burial or removal permit,giving the date of burial;
(b) write across the face of the permit the words"No person in charge; " and (c)file the burial or removal permit within
three days with the registrar of the district in which the cemetery is located.
5.The person in charge of the place of burial,cremation,or other disposition shall keep a record of all bodies interred or
otherwise disposed of on the premises under his charge,in each case stating the name of each deceased person,place of
death, date of burial or disposal, and name and address of the funeral director or undertaker, which record shall at all
time be open to official inspection.
DOH-1555(07/18)p 2 of 2
•- . • 2150 DEPARTMENT OF HEALTH
REGISTER NUMBER CERTIFICATE OF DEATH
STATE FILE NUMBER
1.NAME:FIRST MIDDLE LAST 2.SEX: 3A.DATE OF DEATH: 38.HOUR:
MALE FEMALE Y YEAR
Dahlia Lozada ❑1 ®2 04 16 1 2020 09:16 AM
4A.PLACE OF DEATH: HOSPITAL HOSPITAL HOSPITAL NURSING PRIVATE HOSPICE OTHER 48.IF FACILITY,DATE ADMITTED:
(Check one) DOA ER OUTPATIENT INPATIENT HOME RESIDENCE FACILITY (Specify): I AYYEAR
❑ ❑ E] ® ❑ ❑ ❑ ❑ I 04 07 2020
4C.NAME OF FACILITY:Of not facility,give address) AD.LOCALITY:(Check one and spec ty) 4E.COUNTY OF DEATH:
I CITY VILLAGE TOWN I
Mount Sinai South Nassau 1 ❑ ❑ ❑ Hempstead Town !Nassau
4F.MEDICAL RECORD NO. I 4G.WAS DECEDENT TRANSFERRED FROM ANOTHER INSTITUTION?(Ifyes,speciyinstitution name,city or town,county and state)
1 NO YES
907694 1 ❑ N Haven Manor Health Care,Far Rockaway,Nassau,NY
5.DATE OF BIRTH: 6A.AGE IN 6B.IF UNDER 1 YEAR I 6C.IF UNDER 1 DAY I 7A.CITY AND STATE OF BIRTH:(Ifnot USA,Countryand 7B.IF AGE UNDER 1 YEAR,NAME OF HOSPITAL OF
= YEARS: I ENTER: I ENTER: 1 ReporvProvince) 1 BIRTH:
*-a (A.
MONTH DAY YEAR II monk days I hours minutes I I
..0 .2 OS 02 1946 73 yrs.1 i 1 i 1 Queens Borou h,New York
b &SERVED INU.S.ARMED 9.DECEDENT OF HISPANIC ORIGIN?craaorbaurst/utwudacretio~rowaxedenttr 10.DECEDENT'S RACE:gieckoneornwerraraintlr�•Waedea+daemrednadnirsd'orns+xlrmbe:
ORCES?YE5pe*years) A ElMo not Span Mexican sh/Hisparib abno B❑Yes,Mexican, American,Chicano A N WInde/Caucasian B❑BieckEl or African American C Awn Indian D❑Chinese
vI ®D ❑1 C❑Yes,Puerto Rican 0❑Yes,Cuban E❑Filipino F❑Japanese G❑Korean H❑Vietnamese
IA E❑Yes,Dther Spanish/Hwanirllabno(Speedy) J❑Native Hawaiian K❑Guamanian or Chamorro M❑Samoan '
C = 11.DECEDENT'S EDUCATION:Cxeol dNeax erNN6eudesrneet me hpAestdgrreeaksdoladodmmpbrdstore dme Wdeabl.
m > 1 Els eth grade 2 El9th-12th grade;no diploma 3®High school graduate or GED N❑American Milian or ANslra Native(specify)
0 4❑Some cdepe credit,but no degree 5❑Associate's degree 6❑Bachelors degreeto P El other Assn(spedly) R❑Other Pectic IsNnder(specify)
16'. 7❑Master's degree 8❑Doctorate/Professional degree I
S❑Other(speay)
t 2 12.SOCIAL SECURITY NUMBER: 13.MARITAL STATUS: 14.SURVIVING SPOUSE:
NEVER MARRIED MARRIED WIDOWED DIVORCED SEPARATED Enter birth name of spouse
114-38-6207 1 N 1 ❑2 ❑3 ❑4 ❑5 Ornarnedof separated
.
m USA.USUAL OCCUPATION:(Do not enterretired) 1158.KIND Of BUSINESS OR INDUSTRY: 115C.NAME AND LOCALITY OF COMPANY OR FIRM:
I
Disabled 1 NONE l
16A.RESIDENCE: 16B.Coulor RegionlProAnce 16C.LOCALITY:(Check one and specify) 16F IF CITY OR VILLAGE,IS RESIDENCE
(State or Country H not USA: CITY VILLAGE TOWN I WITHIN CITY OR VILLAGE LIMITS?
drSIDENC NY Queens ❑ ❑ ❑ Far Rockawa Hamlet j❑YES ONO IF NO,SPECIFY TOWN:
16D.STREET AND NUMBER OF RESIDENCE: 16E.ZIP CODE:
1441 Gateway Boulevard 111691
17.BIRTHE
FIRST MI LAST IB.BIRTH NAME OF FIRST MI LAST
FATH : MOTHER/PAREM:Francisco Lozada Alicia Montalvo
19A.NAMMANT: 19B.MAILING ADDRESS:(inck*rip code)
Irma 15 Wortend ke Road,Park Ridge,NJ 07656
20A.1❑MURAL 2Ib CREMATION 3❑REMOVAL 4❑HOLD 5❑DONATION 1208,PLACE OF BURIAL,CREMATION,REMOVAL OR OTHER DISPOSITION. 20C.LOCATION:(City or town and state)
MONTH DAY YEAR
6❑EHTDMerAENT 05 04 2020 ! PinevieW Cremato�7 eensburye New York
• 21A.NAME AND ADDRESS OF FUNERAL HOME: Macken Mortuary 1 218.REGISTRATION NUMBER:
3930 Long Beach Road,Island Park Village,NY 11558 101-
22A.NAME OF FUNERAL DIRECTOR: 1 22B.SIGNATURE OF FUNERAL DIRECTOR: 122C.REGISTRATION NUMBER
I� I
23A.SIGNATURE OF REGISTRAR: 1 238.DATE FILED: I 24A.BURIAL OR REMOVAL PERMIT ISSUED BY: 1 24B.DATE ISSUED:
MONTH DAY YEAR MONTH DAY YEAR
ITEMS 25 THRU 33 COMPLETED BY CERTIFYING PHYSICIAN--OR-CORONER/CORONER'S PHYSICIAN OR MEDICAL O MMER
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:
ACTdnMoCcomb,wD Month Day Year
Alvin Holcomb,MD 191835 ► rEilectronicarT S nett r 04 16 2020
Cer iNer's Title: ON Attending Physician O❑Physician acting on behaff of Attending Physician Address:
1❑Coroner 2❑Medical Examiner/Deputy Medical Examiner 1 Healthy Way,Hempstead Town,NY 11572
25B.K corona IS not a physician,enter Coroner's Physician's name 6 title: License No.: SVn0re: Month bey Year
►
25C.If certifiers not attending physician,enter Attending Physician's name 8 tHb: License No.: Address:
26A.Atlendiop physrcan nth D Y r Mh Y 26B.Deceased cast seen alNe M Y r 26C.Prowuw c d N nth Y T
ine
attended deceased: FROM 04 07 2020 To 04 16 2020 by attending physician: 04 15 202o Deed ON 04 16 2020 AT 09:16 AM
27.MANNER OF DEATH: UNDETERMINED PENDING 2S.WAS CASE REFERRED TO 29A.AUTOPSY? 29B.1F YES,WERE FINDINGS USED TO DETERMINE
NATURAL CAUSE ACCIDENT HOMICIDE SUICIDE CIRCUMSTANCES INVESTIGATION CORONER OR MEDICAL EXAMINER? NO YES REFUSED I CAUSE OF DEATH?
N1 02 03 04 05 ❑6 ONNO 1❑YES ®0 ❑1 ❑2 1 0❑NO 1❑YES
CONFIDENTIAL SEE INSTRUCTION SHEET FOR COMPLETING CAUSE OF DEATH CONFIDENTIAL
- ApnmDxlrAATE WiEAvu
30.DEATH WAS CAUSED BY:(ENTER ONLY ONE CAUSE PER LINE FOR(A),(8),AND(C).) BETWEEN ONSET AND DEATH
PART I.IMMEDIATE CAUSE:
(A)Acute Respiratory Distress Syndrome I unknown
DUE TO OR AS A CONSEQUENCE OF: l
(B)Pneumonia 1 unknown
_ DUE TO OR AS A CONSEQUENCE OF: 1
(G)COVID 19 I unknown
• PART it.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
O YES
31A.IF INJURY,DATE: HOUR: 31B.INJURY LOCALITY:(City or torn and courdy and state) 131C.DESCRIBE HOW INJURY OCCURRED: 1310.PLACE OF INJURY: 13NE..INJURY AT WORK
MONTH DAY YEAR i I 1 1 ( ❑g ❑1
31F.IF TRANSPORTATION INJURY,SPECIFY: 32.WAS DECEDENT 33A.IF FEMALE: 33MONTH OF DEANERY. YEAR
1 0 OrmiDaaaW 2❑Pa6erger 31:1 PWesttian HOSPITALIZED IN NO YES 0 N Net pregnad Within list year 1❑IhepmrA ar ft.1death 2❑Not prepw4 but pregim within 42 days at
or d