Koktowski, Joyce Pine View Cemetery & Crematorium
Quaker Road
Queensburyl NV 12804
(5I8) 745-4477 or (St a) 745-4478
FUNERAL HOME: WJ� 1
.-_-.-..___ �AillE,nl�._
_..-_ . __. RETURN TIME DATE 8 TIME REMAINS ARRIVED AT CRCMRTORT:
NAME OF FUNERAL DIRECTOR OR RFGRISTERED RESIDENT DELIVERINGREMAINS.
NAME GD' _ M' KTD�$ . _ .
TYPE OF CONTAINER 1 -/-- - -, DASESEp
PLACE OF DEATH: ID7 --FORT yMv
TT4 Lb w
ESTIMATED WEIGHT OF REMAINS 8 CONTAINER
PLACED IN HOLD:
PLACED IN REFRIGERATION __
DATE OF CREMATION I 1 - ' ---'---
TIME STARTED: - -
. _- ,'uD TIME COMPLETED:PLACED IN RETORT _
7;3D � _MOVED
RETORT II IN WHIC N REMAINS WERE CREMATED:
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORF TNgry qR HOURS
FROM TIME OF ACCEPTED DCLIVERY.
NOTE. IRA CREMATION
5 LL n[ RETAINED g I HE PER MAkENT FILE Or TRY cx[mnionr.
sume
OapaNnanl WnMeb
NEW VORR Division of DWIMM OF CEMETERII�STATE OF emmarcaP
OPPORTVHitt. I Cemeteries ssewStAyNs0]SLWs
Cemeteries release" (SIC p
Authorization for Cremation and Disposition
This AuMcN Om Form meet be completed and signed order to Ealinry of remains for cremation.
Date:OW11120M Number'. ID 13
Chamber Name:pine View Crematorium
Md� Quaker Rd, Ow enabury, NY 12804 pAwd 64) m-1(o"f'1
CREMATON IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation is ponied out by placing the remain of the deceased and the wM ,nor Holding Ilse rem&na into a uembun cM1amber will
they are wblecled W Intense heal and flame. The hold and flame will IrrcinamW antl consumer owry ing "i bone a"mark,
which en at I Nat All Ides At aNn b rmetlon.
Following cremation Me crematory MN take reasmade eXorbb mrnve all of the remains bad Other meedi from 00 oematlon
chamber, but some minimal dust and residue will likely be left baitlnd. "a crematory mil sey9te Intidengl and foreign metal lmm
eta remains and understand and Craig,real will be disposed of as required by law. The cremated remains wall as mechanically
ouNende into wall Cane;and Placed Into a desgnated container or urn CremaNd remains gonamily are pulvarfaad until no
single fragment Is recognizable as skeletal Nesue,
OPENING OF THE CONYMNER
The mmetay may wry Vert me conlamer holding the uno,& aWd human remains in limited circumstances,war as N Noonan the
hummanchremains am delivered All
coamonwea ieh,newt suiabkurt[rcmYlon such surermomn bul lam$W,wine N
inlet owill clew Nu rt m ahe amm he moved Into a suitable careful deta u Wake, icupN m rem a alms. The opin m eng a
crams be r Me cant or remunl of remains will No wnelted bmore a sol and Aik be done In FrAcy with don"ind towed,
IDENTIFICATION OF DECEASED
Name W Oacaasa]'.Assay ber mll Mam S Nevin Wa i l
Last Known Addrew 10 Coud St, Hudson FNh,New York 12M
Place of Death 10 Ccun St., Hudson Fell.New York 12M 11
Su: ❑M El Pqe 65 DOB: 10h7/19M obleomo01:W1112020 Eatmm@d WNplll: wf
Dazcrlolgn of wskeVmtb'ute,in which remains All Me deRws ,
Matthews Casket Co. Cremation Case - oaroboand top, pIYY bottom
PERSON IN CONTROL OF DISPOSRION
(psmon(al in an adlw 5fl dljl (I M the Complete)
I wNWe an be designated agent W the dcasW dASN"MMIn a MY or marmtreWmenl a Wmrwent to Public
Health Law Seeart 42D1.
0
poll Wn no knowledge Nat Me demaead wow d a wnden Iinstrument numbers N Public Health taw session 4201 or
All
otsmng dhamcrs far Me dlspw[Uon olhu a,",remains and lM am Me fambris having oniony barer Public Health taw
Sectio,4201 and have the right m aNhonce barrel of Me remains of the deceased. MylOu,nlnlonmike to the d....sa Is as
mnmi
Joyce Kaktowski
DOS-189af(Re, 0420) Page l of
Authorization for Cremation and Disposition
line lmn)re sal Me )
Number DesalpdOn: w -
1. A pelmn deslgnai In"Ong purauanl M Public Health Law SeNOM301(SII
]. ma sumari ;smum;
ga. The survorg deM"tlC paler.
5. Any,sundving child eighteen years of age or ewer:
a. Asuri therend
5. A upward sibling apMaen years N age a chair;
P. Alawfully appeared an ion:
]. Any warrants)nghtrensees of age or older entaed to sharem the estate and wed iyae tloegt in MaOonMlp M to dam
B. A duty appointed Mucarytit the estate)
B. A deals friend or Mauve who has secured a woman statement pursuant to Public Health Law Sedicn<]01(]);
10, A Hearfiscal off mrtit a county or a pudic mad ministretd appointed Pursuant to the 5urmgaa'a COW Pmzdure Atli
10a. AM other parse who is acting on crash M Me deceased am MO loss Annual a when w dwmenl Wrsuenl b Peak Heats
Law Secton 4201
nn L THREE of Ma Bilateral
Me hi an"Mat Me Icy of the denmaed Mea nm mnMm a baWn. ls11W each,power mat Mdio.cllw ended.
or 2dioecive device and Mat any such me4nals were removed Al M the execution o1O1s AUMowa ,Form. Failure Mremove
hn5 poor M crema0on may result In harm M the crematory and cramMory"Ronntl.
IArge affirm that treWcticns have bran given to Paul M.Diecti uervum
hapaNing the removal A any career cement,or oNa Ming of race which any"men signiy bear,or any family member of Ne
deceased wishes to resume. Pine Vlax CRmawer,
is not Retrocede Mr the removal of personal hems"an the container or man the remains of One dereased. Personal Hans left In the
30 or with the remeine will be destropd by Me comment pm ms and unnd be trimmed after cremation.
Me her auMoi Pine Yew Crematanurn
M aamaa Ma enter My of the dewasad.
far n0i
7towe hereby euthodu Ms named funeral director M provide for delivery to and enmatim by an alwmaM
ebry, o deemed necessary In the opinion at the fineRI dimmer.and M amend an Is form to provide the marred name arrd
address of such alternate comment.
FINAL DISPOSITION
Tbe permh aWl W to aftel my adhmMd mmame of the dewaeb from Me Miami ie:
Name ,// /cis L
Address 13 1 F Ee Pherw:
The central remains of dowsed will 4 dmvvvd of asfilows:
Returned M hell
If W any reawn Me nmaned above 0.res not to its generation of Me aemated remains.
Rne View Cranawmm is au0v¢ad M ova gewe4on of
Me mmairs M CameroonCameroon, re r, tHMO. Inc. �mm•r by demary
In freers Or by registered mail. Joyce NNbanMl
DOS-IBM I(Rev.dead) au�r Ppe2WJ
Authorization for Cremation and Disposition
X((y(y(I(M(olbwupf
�. N2euMenmMIM1et time remains a,enm Calmed v ,n IZD Oar Of cremation.
Nmvlewceemelonum may debate of tM remains in
an memavable manner, such as by t tOn. nuinmc�rwrvt
CREMATION CONTAINERNRN
(Inn ONE W the bpawmg)
um Is be need as a wnlainm br me amabd mama has been purchasers M1om
and is described as fall
eve understand that If Meam,$me small To Wit Me entire cremartl remains.an sideffifernal read consular may is used on tlfil
-0R-
um a rot had purchased here understand that Ilea um is purchased or obill pmNOW
Rea view cm ammim arl passe the ryemeuh refueled In
a said Treatments whether air deial eenao a�
This f u1MNaal Form was provided by Raul M. dtlleA say mrsnNs]at
Carleton Fusion Nome, Inc. M�wnmu�t
P 0.box 67. NWson Falls,new tors 12MO fswuw+wm
and IalouW by the funeral director as entrance to its exxules.. �w
Me have nerved a wmpleled wpy of gas Automobiles,Form.
The warrants)IdeMlfled balm ILere the damage)In wnbol of chspwltian,who by signing Poe dimensional Fame attest(s)
b Me accuracy and comp ness at the Informagoncentered In Met seaonaallan Form and numerical the braving.
Signed this ll May SeptaMor 20 2D
/ use
11K/�-ds t Tkld L /Z!/0
Paul M.Obmm �-
suuaMa.mrw+I sl—i.ewves�w
togGfi
bym NOMbwsM
DOSISSbf Stow.ONNI) PISI