Klomann, Siegfried Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: _ 4A PM�TF RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: 1,11f im ID.7GAn
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
_ . jk8NE 00000116
NAME: STti UFRSEDp t/OMANfJ CASE # 733
TYPE OF CONTAINER: IAPAIYAPD W / NOGD FEAR IFID&sNPE HL
PLACE OF DEATH: _ S i'111i i Li)l m) art(( k4 I#Ar
ESTIMATED WEIGHT OF REMAINS & CONTAINER /To S,r
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION: VJsl O
TIME STARTED: .___ IO"HAll TIME COMPLETED: �� I4
PLACED IN RETORT: 110 An MOVED: II �At1 2'IDPI'1
T
RETORT pIN WHICH REMAINS WERE CREMATED: . _ _ S�jL_ Rn2RFIL
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.
pap.remn�wwu
SBWYORK Division of DIVISION OF C1.vi Fucaa
srArFo� o c ores
Areas W
Cemeteries
Twmmw.,SW,a,.pg�
Authorization for Cremation and Disposition
This AmMxWmum rem must be complabtl anaelgnea Minorco dismiss,of rememe Wrcrema4M.
wta 061=20 Number: ')33
Chambers Name: phis, Cremabry
Address: 210uMM ROM, QWm q. NY rates Fame: (518) 745JG77
CREXATON IS AN$MVEMIME AND FiX PROIEAG.
Cremationfly carried out b/Mean The remains or Me esma aid tlN ttmalrer molding INa comedy No a vemalicnc mmrx m
Meyamsubl 0,nln heMaM flame. The hear and flame will Incinerate and cdumnsanr ing mal Wm and mall,
wM1kh are all Met will be left after cremation.
Follarirg Cremation, Me tremolos,will Wks reasonable Mom to remove all Nate remains and Mar Miami Me vena00n
CFembx, but some minimal dust and meita ll likely be laid behind. TMUemOory,will separate Inpdemal and Morm madnal from
Me remains ayes Me monsoonal and real Mall sell be Mpc¢ed of as r Ulred by law. The chomald mmalm will by,normalmlty
pulvenaeo Mu wall pieces and placed Ike a detigmWd consular um. Gmm&W remains Mora lly am purerXad ul no
single lragmem Is nMgnluble as&MIMI msus.
OPENING OF THE CONTA XER
The cremmory may only case Me embassy holders to ui cmmaW human remalm In limited umumstanms, such Nb mnfirm Na
All Moe Mwa arousal Met m message;Well whion might injure empl0yces ohmage Me cremetorypmasM N
human Wan lm am delhared In a Mrlhlmr"lob W not euMble for cmma"n such Am commonNi ornnM1l casket Me
maday Mll requlmthat Me mmalm be moved into a suitable cony leer WON X"cape Me ramelru. The rysniy Of
enWiwr orbs consumer removal of mementos be mMuc cadre Awmass and vnll bs cane In Fr al veto dpnMaM Imyct
OENTF CAT M OF DECEASED
NameMCe®ewd_ Smighad Kbmenn MaML StaN¢: Mwmm
Mst Known PGdrms'. B Wa1150ced, Unit M5, Charter Paris. NY 1Ms
Pore of Deets, B Wall StreaC Unit RS, CIihm Park. NY rags
sex: f]M ❑F Aga: 86 uM 01/03/1934 p ofm . Danurmxo EWMa WXgflt'.
D"nroMn of vkepmhniner In whim ra norm all F9 deererM.
Cardboard Box wMooden Base 610"doll n.ill)4
J
PERSON INCONTROL OF dment mom X
(P»m(s)in cvnbdd dgooMM. NXIW ONE o/Me locoing)
I MAW are the designated agent of Me rammed detigmed in asom o Wagon instrument executed pursuant to PmM
Heats haw BMbn 4a01.
u0JT�-
1 K IM14B have no knowledge Mat Me deceased scandal a wdlon recommend Pool to Public Health Law SedlOn 4201 or
All carte rig directions Or the dbposilion of his or her remains and was am The harmonic) having pMriN under Public Heats Law
Section 4201 and haw the yes b Waterloo cremation of Me rem aim of to daxawd. Nyour mindo sup as the dace"M Is"
farmers
Siegfried Klomann
parya
DOS-18i(Rev. Wxm Page 1 dB
Authorization for Cremation and Disposition
nrwdmom they mfMbw)
Number CmmVom: Renard,Kbnenn Sperms)
v Apmson 0esMnafetl In w hang pursuant m Public Heats Lee 3emon 41
2. led survrvmg money,
L. The reveal domerec prover
3. Arty surviving cmd engineer years of age Or Mccr
.. AMeese pererM1
S. A w riving soling eQM n"am M site or doer
6. AlewNlly appointed guamlan',
T. My persons)equaen years of age or Order ended b flare In to eeW also whopram honest in War ship to the Manua :
& A duty appointed neuumy of to eders
r. Adwe blend or wouw who has Removed a wrlem acronym pursuant b Publie dealt Lax Sandon 42019)
10. Aone(feel officer of a mumy or a public interstate,a(golmed pursuant b the Sung sCourt Procedure AR
has. My mbar param wfe is worry On benan of the decNeed and who has eSaN E a written metal pu muam to Public Hei
Law Section@o1(7).
ppN1�/ALL THREE a tlm I r)arses
R.K Mae tenor affirm that Re birds of the de ddoes min mnoma Memory.batlery par, Fewer w0. Adloaaovs unwrm,
orre muctiux device and Nat any such mansmosw reremoved promo Nearalcumn ofmis AuMarhawor Form Fellurebmmove
these Items mores cremeal may result In Nmr more crew"and cmmrbry proonnel.
R.K. li infirm than lnabubeem he"been given to Rdond G. Intel
regarding Fee Rma/sl of any personal propeM or otler doing of value wkM any perbn Murphy more or any harly,n Fof 01a
de sad Mshas b prowen. Pin Nix Cnmetmy
Is min reference 1m the A l of personal hymn more me conifer s from mB remain co the deceased. POrmnal Items"In the
wnnblir(mr or with Na females will hey dommayed brine cmmmon process and impact be rNMvrd after cmnstlon.
r I _tNh Mrobr aNhorhv Pine view bread
b cmnso No remains W tM decevnt
pow OPTIONAL)
Wn Mmby numerous the named Iunerad dlrecror to provide film warIi b and comvtlon by an alternate
nmabry.It creeds necessary In Me opinion of ore turenl sunder,and amend this form b provido Me correct name and
address of such aNxnvo cremabry.
FINALDIS MSITON
He existencehmiced he Pascal to(Tamenee mmelme Of Me dewawd morn the sensory in'.
Name: Compromise Furenl Cam
AMA: WE Maple Rex., fixabga Sgaga, NY 12M Phrase (6ln fifir'<Sr0
The tlamaYd remained of deceased will be diap'ead hies Mi
RENRN TO FAMILY
If fw any mason 6n Real named seem dead rMbYe pwenicn of the are mMhu.
Pine days cmre bauN Wmdays model Of
manmomb mswvrw*rl CvrNw MFureml CYv. arc by Mlilry
Mi or Mail by Mo mail. p��rti
in M S]Med l(kmaM
DOS-1Bgbl(Rev Ornd) ysm Pays 2 of
Authoriution for Cremation and Disposition
!I➢I�0iIl(th ldMin91 '
ii.K. IMb undeami tha111Me remi are nm aaImNMNIn 120 days of uemaoon,
Nm New Cremalay may aspose of has miin
en rtreNevede rtwnucnwu4
manner such as by stlenn9 a, ca
CREMATIONCONTAINEWRN
(Moo ONE of To Demmer)
M um to M used m a assets for me ime ab]Rmalns tom been puwdi man
and 0 descnbM as bllova:
IMb urgeraWld Nal iftly um IabaEmellb Mb tlaenEn vemale0 remelnn, en a5]Itialal rpC cmbknmry M wMbr WINay.
p((R y
7 .K Mum is not M Wrdased, LMY Unchoul A OW 0 no um is WrWaM or commase provtled
plrc Nry Caiulay vnll plym tow manhood remNns In
rmwovawn
a Mid lempmary mnlairaw for delWa
The Audiovisual Form was passed by RolaW G. Hap was finished at
Commonness Furerzl Care. WC
CM amid Aue., Sammie Sla . Ny 121105
and is.Chad by the mlwal dlrecmr as wnnna b b a wuhon
Dim have mammal a wmplaled copy of this Aumorhatlam Form.
The gmon(s)Miam tl below IaM1atlw pammrlal in coMml of composition,who by signing MY AYMwUa✓an Form.$ti ge)
m tin accuragaM eompMbnesa of tiro Informi conM1lrrM In NY AUMorbrafkn Form and auMMuls)Ms brpdng.
Signed this tah day of NOM .20300 / )p
Rana momann
Byes Sbasl WRU5, Clanton Park, NY 1M
W ImRdi
lvm G.�Imp
1fG18 rnvux�l �
SIpMed KKmam
DOS-189611Rev. Cii Page 3 03