Koeing, Wiiliam Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: _ co l
- � - RETURN TIME:
DATE B TIME REMAINS ARRIVED AT CREMATORY: S NAME OF FUNERAL OIRECTO0. OR REGRISTEREp RESIDENT DELIVERING REMAINS
ut_ Ri3,4
NAME. _ y �/ULC(L I_,I okprG _CASE R ___.
TYPE OF CONTAINER: __. m(1R4ST...__... LU((1 : F _lI
q!IC
PLACE OF DEATH: 1140 _
ESTIMATED WEIGHT OF REMAINS 6 CONTAINER.,_,_,
PLACED IN HOLD: _ -- —
PLACED IN REFRIGERATION:
DATE OF CREMATION: $ 7L .N
TIME STARTED: ____ 1�11-- _ TIME COMPLETEO: __1lV1PI�
PLACED IN RETORT: ip:Tq ).D6 II
------ - T//,1h .__MOVED: --- __._.__L..
RETORT a IN WHICH REMAINS WERE CREMATEO: ,
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN AB HOURS
FROM TIME OF ACCEPTED OELIVERY:
xEMsiogY.
NOTE: THE CREMATION LOG SHALL DE RETAINED IN THE PERMANENT FILE OF THE C
rkSne
by ft WsY
—J NEW VORK pIVIs10R Of Dmslol�oF CEMi ..
j — STATEbF NOFUmera ES
Cemeteries saw „^;;°Awi°re
2T000l
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Authorim lon for Cremation and Disposition
This AUIM1orleNon Form must Im comp and signed prior W Celhrery of remains Ip Cmn On.
Date; 05121I2020 Number (e�yF
crematory Name:pirte Vl Crematorium
Address:51 Quaker Road Cueensbu NY 12804 PMm'. (518) 745-0 77
CREMATION IS AN IRREVERSIBLE AND FINAL PRMM.
Cremation Is comed out by Rhodes remains of the do and tM container holding the rtmaim Mto a remotion Mentor Wen
they are subjected 0 intense heat and flame. The bass and Rome will Inclnee eM emsunw everyMing moment boom eM m L
"fell am all that as I be IaR*Nor cremation.
Following Cremation, Me uematory will take Rasonable eNOM to re all of the remains and Other motors I from the oemban
chamber, but some minimal dust and residue will likely be leh[ehind The oemabry will eeParete Incidental and foreign mail Earn
Me ramelrs and the incidental and foreign material will W elemental of an Occuired by law. The mmele]remains will be mechanically
paramount Info smell pis and Placed into a designated a Wneror um. CremefdR imgene llyan Mlvokdu"lno
single bagmen u rocognlvble an ancient Monte
OPENING OFTNE COWMNER
The uem.bry may only Oman me container holding the um.uemated human Nomura in limited circumstances.bush 89to mnhrm tM
Nemlt,of the deceased oto ensure that no malenal Is incurred Much mrehl moan employees or damage the crematory anyway. x
human normal oate delivered In a mnalme which Is not a Who We far cremation such m min Wl or mat lmbt Me
mmtmy will End Ann t gNOman he moved into a sucrose mnmmr beMm it accepts Me mmlm. The owing of
mnlarer or the monarch or removal IXreMins"it M conducted before a whnaco ens win be done in phase, with dignity and impact
IDENTIFICATION OF DECMS
Name Of Deceased: William Koenig Mantra Sulu; Merr'led
feet Rmwn omren:1260 Want Mountain Road Apt 119 Oucenoury NY 12804
Ram f Dead,;, 1250 West Mountain Road, Apt 119, Q] nsW W, NY 12804
his: ®M OF age; 92 DOES; 0&2711927 DaMofOmyt; 0612112020 ENNuled"m: IXl�
DmMr
a Ireummeimarm wfdr fllbeaxymred. pp
ERBOX INCONTRM OF OI MMON
(p S)inmnwr aarooadion,pNypf DNE of me kAvaingl
I emi are too designated spin Mlle demos dmlgraled m a wit orwritlen instrument e#C puauef W Public
1 oM taw Setlim 4201.
'OR-
mAk Me man no Mowledge that the der»aaed execution a~ instrumentnusumto Public Haab Law Sector 4mlora
MI COMamiry directions 10 Me MsPmwon of his or her remains and Iran are Me p on(e)having priority under Pubuc NmM Law
SSEon4201 and lave Me ril authorize cremman uttie or my MMe dwmm&d. *fur mlatiomhlP tome deceased to as
raper
William Koenig
DOS-18W(Res Ml Pepet WJ
Authorintlon for Cremation and Disposition
Amen from the rur below)
Number: 2 oescrip4on. Sitionse
1. Aper¢onE 9na In WNW parmanlb Pudic MAN lw 3avon 41
2, The aurvrIN squ¢e;
2s. The sumrmp mmedc porymn.
1 My suPnHne third eipmen were Nape«of
4. Asuni base
S. Asurvmm0 ¢iming eShtmn yxaa of any or older
e. Alamuly appolmaa 0ducan;
T. AM Person(¢)Woman yam of age Or NOW entitled W share in me Mad and who Were cMal in nlationMip to Oal J new ;
e. A tluly appointed fiduchery of the edab
9. AW¢e Mend a release Who has eiecumd a wrimin statement pursued W Public Health law memor14M1(7);
10. AON fi¢ml ottiwr of a couny,or a public admniWa regwir pursuant W the Sumpele'e Court Prc¢Oure A6
10e. Any other person who la song an GehaH of Has deuaeed and who We eseunN a nMWn Named pursuant W Public Health
Lew Section 4201(7E
(N�ygi yTALL THREE aNe foncommi)
f/ s—lMb hereby elfirm Matthe EwydRedeceaeetl 0.va m(wmainabaXery, bemgpack, powervll, Mdioectiw 'IMPWN�
a redioxtive deNce and that any¢uM maleriela wen remu+M prbr W Ne excufion olmle Aumwlvlbn Farm. Fmilunb mnov
MwaIlwv prior W cnmetion may nauN In arms,to Me cm Ma and criminal Anomel.
111.8K Meammthaldbudbnshewe ngyenW aVyM mBul'gh
�e
mgwdlrg tM removal a my% m,gcgM maNar mkq of veLre whdi eM peson sgnYO Ni or It Hy nw rby tle
derseeed wishes W Intel Pine View Crematonum
a na reWonWbN mrthe nmwel ormrscnal itan.bone mecpmlnerw Fommm me mm.�ns atne eeo�ned. F.nonel lt.nc tan lnm.
mWimrorwnnthemmimwanmdeaw bythecremationmammaandmnnNWmb ofWraamation.
We hmW ammme Pine View Crematorium
War the rmalm ame Gaaawd.
I ndiN OPTIONAL)
than hereby aumome the named humid Window W provide for dsllam to and cn lion by an an w
cnnutory.N deemed necessary In the opinion ofMe funnel director, and to amend this form to prooft the correct name and
edmass Of such aNamate CMMa[ .
FMAL OIS'P00MON
The ammo athomed W reserve He ve tefr ins of Me dmavd hom the uemamry'a'.
Name;Singleton Sullivan Potter Funeral Home
Addms: 407 Bay Road Oueensbury. NY 12804 Bwru: (518)793 459
TM vernaed mains adrteewd vet be as(.atl dv Mb :
Bunal—Cie Id BH &AMmon Sarintragat National
Nfm Mr Me mrear named eMve does rM Wz po¢mesion dCe awnaetl named,
Pine View Cremutunum wetmvimtlWyvpaaawfana
the M sim W Singleton Sullivan Potter Furrerel Home by" at
w m. r
W pertm wby replWwa0 they. W'II'em Koeng
wauo.�a
OQ+IBB6IIRer.W110) Papa told
Authorization for Cremation and Disposition
lithe twnwmiol
m®k Mee unaterYandMetHMenmaim are not clear when tN care duem m,
Pine View Crematorium mvydapcaedMeremainsn
an im0ievaae menrcr, such as ty scattering.
CONTAINERALMIN
none ONE dIM nowevig)
M um to Ee used as a wntaY then " remains helps Caen pacM1eeetl M1am
will is estimaM eaMlowa-
mass uMeretaM Met KMe an take small se beho Me entire vemaW amounts. an aaMtlmel rigid container may buMher tlelHery
.OR
Meal u ierKKyslqucNee6 WN UMenteMMNHro anY WhnlhaaatlaNwwYeprnitletl
Pone View Crematorium was place the cremated remains ,
cweaown+ry
a mob tem W nary container for delivery.
This Authorization Fmm was prontlad W WendyM Bulich was exeiat
wawwa
SingletonSinglamen Sullivan Potter Funerall Home
Q7 Bay RoeC, =n'$Wq, NY 12804
m�+w.aew
are is signed by Hp NMld Moscow as WMassto be exeauWn.
We have hear a cometN ashy d Mhe AU Mzsr Form.
The panonls)IbmtllMtl CNDW bases this per ni In control 0 dlspwltlal.wha by names M4Autlro/tratlan Form.a1Mto)
M the accureay aM wnplpenns Mtat Inbrmetlan conralne t In this AUMaisaeon Form one s ndorizale)IM Mnpdng.
signedthls 21st dsya MaY in 20 .
Made B. Koenig or i c
+rrvsr..
1260 Wiest
t MOUnlain Road Apt 119 ptxerlsbury, NY 12804
sea.
WITNEas:
Wendy M. Bulich
v�waxm,rn.esau.ae.re
lwl
WNI'am Koenig
a..wev.e
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