Surko, Jason Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745.4476
FUNERAL HOME: �$. _ q_ RETURN TIME:
DATE ATIME REMAINS ARRIVED AT CREMATORY: 1fit z
NAME OF FUNERAL DIRECTOR OR REGRISTEREO RESIDENT DELIVERING REMAINS: -
— K4cE �CyN@
NAME: SMeq CASE R _ T3
TYPE OF CONTAINER: (G kot G .qR jD'(El
PLACE OF DEATH: z�Nw L(Y_-g• AK LW LRL i� �1*1
ESTIMATED WEIGHT OF REMAINS A CONTAINER NER ISO IL
PLACED IN HOLD:
PLACED IN REFRIGERATION: _
DATE OF CREMATION: _ O
TIME STARTED: T'KRI1 TIME COMPLETED: gOSA^
PLACED IN RETORT: _ 9%An MOVED: _ )D:16A11 /}pIp/In
RETORT B IN WHICH REMAINS WERE CREMATED: fhvf REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LED SHALL BE RETAINED iR THE PLUMP MENT FILE OF THE CREMATORY.
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Authorization for Cremation and Disposition
"is AuMomftan Form must Ca comPM d and signed poor to delivery of andespe�la comets".
q
owe'.July 7.EMo Number 3V3
Churl WHO, Plan Vlew Cremalay
Address:21 Quaker Read Gwensbury. New York 12804 Phone 516745-8116
CREMATION la AN IRREVERSHILE AND FINAL PROCE85.
CMMOMus carried pN by Al they remailu as the de art the cordamer backen the m Wnsinb a m WnMamlw'MNre
Meyare"Wry iM mheelendflame. The nulvrp flvmBwlll lra'Jmvband eomune ewryMinp axtplUOrN erica Metal.
which an all Mat will b Its after Creation.
Following cemglicn.Me aetraMry tall lake ressoneble eXoM1S to remove all of Me remains and either riaumbal"in Me Gemetion
Member, bid soma minimal dust and resesue all likely as led behind The creamy will uparate lnudentel and foreign material brim
Me remain;and the Inddentel and foreign meknel w01 be deposed of as required by law. The measured remains will be mechanically
moreezed into small pieWa and Anwal into a distinc tl container of Cmmv mmtlm gvnnally am pulvenaed untilm
Nrge fragment Is recognlvbM an keletal tissue.
OPENING OF THE CONTAINER
The crematory may Only open the cournmer holding the unuemaled human remans in limited orcumstal such ae to confirm Me
identry MMe deceased or to ensure Mat no material is encored emon might inner amployaes or damage the crematory Mercury It
human mmaine are delivered in a container wh lM is not su ode for emmAcM 6uen a6 uremonad Or nnlal wML the
mnelary will summers Mat Me remains like moved into a suitable cartel Were It accepts the remtlm. The opening of a
sidua ar the transfer or removal of remain:mil be conducted before a witness and and be cares in pevacy, windignifyandrepa].
IDENTIFICATION OF DECEASED bwo+ccd
Name of Deceased: Jason Burka ell Stafts +
Lest Known Address, 21 HemgMy Ave Glens Falls, New York
Place Of Oats: 21 NemvMhy Ave Glens Fair, New YM avI
say: ®1n OF All roe: 12E-1979 oast of Dennis 7-5-2020 Eahmaed Vaught. 150
oeeoiption of onewme0memn In whine remains At be deliuerM.
Florence Casket, plywood corrugated cardboard container.
PEMON IN CONTROL OF OISPMMON
(Poramlfab In cmbor or dlepawnew BONE OI Me blbxinpl
amNJe we the designated agent of the decreased deignated in a MII or written instrument carol pursuant to Public
Heats lbW Section 0201.
4OF-
Nsedhave re,knMedge Mat the deceased mewled a written inNmment Annual to Public Health taw Section 4201 or a
art 'ning directions for the ciapcalOf his or her remain and mere are the deaon(z)having pdosty under Public Hearth Law
eeaioM201 and base the right to authorize uemetion of Me remains of the de aved Myal MADMehlP to the d&hwwd is all
files
Jason Surko
DOB.1al(Rn. 04201 Prager, ' oft
Authorization for Cremation and Disposition
I rox nl
INJa unEeMantlllut tarts remelts ere rMCeimetl w11Mn 130 tiara of vemalion.
Pine V1ew Crematory
an in&xueble manner, wr ias bys Ndng, OUA uuner Trey tliepaee NMe remains in
CREMITION CONTA NERNRN
(1 0a1 ONE o/the bpawirp)
An um to be made as a coMainar for Me crsmaletl remains has Men pu bermilham M, B. Kibler Funeral Nome
and is described as role"
i nmeMand Mat if Me urn Is No"Ito ma Me Milerumred remelm.art acklmnal dpa container from M used fora Now,
I—An um a net yN purWwd. IMb understand beat if no um Is purchased or aMervlse pmrided
Pine vim Crematory will place Me crematM reme'ms n
a rigid temporary mnl&nerM delivery rvr�+0uwr
Thin AUMomada n Form xge pranded by Clain C. Kmgb "a sxeWetl at
puv.owm ww�
M. B. Y'Imx furerel Wore
Minm
138 Mein St WUM Glene Fells, New VOM iRB03
eM is signed by 1M bvIMW tllre[Ip eswilneu to ib eaewl'Miftni,mms
Was have income a complated mpy of this AumWtrNan Form
The mmonls) idenOW Mlaw lama hors"=rile) In con"I of Mapwitian,who bib signing Min Authorization Form, atlesgel
b the accuracy and comgabneu of the information contained In Min Auti H700on Form and authoiiets)Me foregoing.
Signed Mls Th day 0 JOIN m 20
Use Kline
21 Kemvo m Ave Glens Falls, Now YOM II1101
st
WITNE88: 1
OMMC. Korcµa
r o-maaww �.r amvsa.wa
1102
Jason Surko
OO$ la%f(Reu0A2M Pege3U3
Pine View Cemetery and Crematorium
21 Quaker Road
Queensbury, NY 12804
Authorization to Separate Cremated Remains
Funeral Home b,,6 Kilmer Formal Home, 136 Main S SUE NY
Director Claire Konorka
Date July 9 2020 Tag No. 80
Iiwe autborize the separation of the cremated remains of Jason Stake.
Uwe fuller agree to hold harmless, indemnify and defend the herein named crematorium as well
as their representatives, from and again et all claims, liabilities or damages whatsoever which
may result from this auffin iration.
Signature
Cremarory operator
Ma"2015
Authonzatton for Cremation and Disposition -
Numbermm Ale wf ermw)
xumBer:! oemiplron: natamidne wrest
:. Tnperam dnsiena in sang wrsuaM b Puac Herne lYx secllpl/2a1(a):
g souse
L. The larval domesto partner;
3.A AAny rvnrvmng child immeen yaam IN age or older:
5. Awrvlvio parent
5. AlawNll dealing sibling adr years gage orddec
r appoirrea guaralam
e. qduly m°n)`) `gmeen rears q spa croMer enmled a share m Neaslne and MoiWare unseal mrelaennsnip O ttedxewed:
ppdmed fall of estate
s. Adoes Mena or rellive who has eaecukd a written statement pursuant to Pill Team Law Section 4201(7)
10. ANWMust Officer of a worry or a Pal who iMastor appNnletl pursuant b Me Sunepale a Court Pmgdure Ad;
Wa. My offer pmson who're acting w behalf IN the leaders ant who has¢:Wded a mean statement pursuant to Public Health
taw Sedan amtp).
7THaFE of the mvowlny)
All nmeby all that the M1y of the deceased does net wMam a Batley. battery pack, power an, mawdlve Miami
or r dal deal and that arty such mournful removed primto the steel of this AUMomical Form. Failum to mnove
Np a prior to enteral may neutt in lam by Me chMlelory and cramtlary p nnO.
IAlle aMrm Pat lnstmtlgre lave been given to Claire C. Kcnopka ummw
regaNing He remoal of any wraonal prgMy,or order thing q value vmi¢harry prem vgnim Wow or any party member"Me
tl&xamdvnsheB tO prearve. Mine Creme
Is nor reasonable M Me removal q wamal items hem the container ham Ne remarna INlhe d¢reased. Personal NemeiMin tly
considner,My valued Me remains fall Be deMayad By the cnmal Procne and cannot Be reMeved after cremation.
INS Model ar fize Pine Vlex Consul
to Cnmab Me ramalM q Me 0aceaeetl.
tlmildrovnoxAy
Idea henry auNoan the named formed dire arty provide for delivery to and crxnel By an tlbmate
maary, Iftl " essential In Me opinion of the forest tlincar,and aamend Nib amr to provide the correct nme and
aMM q such adbmah oriental
D
FINAL O SPOS T OH
The permnauMoriZed To nmiee Ne uemalW remains off Me tlemased home Me Gemaary 19:
Name'. M. B. plmer Furat Home
Address, 136 Main Sl. Soup Gem Falls, New rely 12BIX1 phone 5W745,8116
The cemabd remains M deceased add M d'upomtl of as idiom:
If eNany reason to Person Mmed chows deals net Wks peoppoan of the cremated remains.
PlanVine Gre "
Aw.neAA.2A rs euNalzed to9ix WueasimOf
the remain Is M. B. primer Fura lHoop r by summery
in pmeon or by refusal mail. header Stared
OOS 18% f(Rev.Owl m++u Page of3