Golonka, Dr. Joseph Pine View Cemetery g Crematorium
Quaker Road
Queensbury, ryy 12804
(518) 745-4477 or (510) 745.4476
FUNERAL XOME: _ 8p
RETURN TI ME: _
OpTF 8 TIME REMAINS - - ----'ARRIVED AT CREMATORY:p _
NAME OF FUNERAL DIRECTOR OR REGRIST ERED ._ Q�E310ENT DELIVERING REMAINS.
NAME: how
✓Y�t- -�_
d ...._-.
CASE N _ 6D
TYPE OF CONTAINER:
PLACE OF DEATH:
ESTIMATED WEIGHT OF REMAINS A CONTAINER_,,,
PLACED IN HOLD: _ �
�—
_1L
PLACED IN REFRIGERATION;
DATE OF CREMATION - - --
TIME STARTED: � pp.�r�(pj��
L9(11.__--�TINIE COMPLETED: - Z;O�o.IR'F1x1
PLACED IN RETORT: I�^(8.I ~--'-
2"Icf' 1._..-----MOVED: - ':)oP Z )c
- -
RETORT N IN WHICH REMAINS WERE CREMATED; '
DETAILED REASON FOR DELAY IF REMAINS WERE CREMgT 3A -
FROM TIME OF ACCEPTED DELIVERY: MORE THAN 48 HOURS
NOTE: THE CREMATION LOG
SMALL
BC RETAIN" x THE PERMANENT FILE OF THE CREMATORY.
oepa"ment Yoe
v OUEPORK Division of oN610HOFCEMETERIES
SOU F ne Cemmera Faxa
Op °"U Cemeteries 91 e^�
,z2amm
Authorization for Cremation and Disposition
This Aumonaanon Form must W completed and signed pi Mllvay of rhmainSfor Crm m.
'.g�29 �W Number. "IW
DW
per" NameTl'Ine new Crematory
Quaker Rwd, Owmbury, NY 12604 51&]49:
Mklem. Pne^e'
CREMATION 15 AN IRREVERSIBLE AND FINAL PROCESS.
Cremation is oametl out by placing the remains of the dweaed and the wrNlnc holding IM remain intoa uemmim Chamber alien
May ere aubp]etl m Intenw heat antl Pem¢. The hod and flema will Incinerate and consume awrything assume burrs and metal,
whlohare all en wiIIbe I¢RaMrcornedon.
Following at some thecremustand flake reeaoikely eflortaWremoveall oe1M1e remains and OlberralmialMs,Men materal
Mon
e
criterion. and M minimal dust foreign
eign measured wh likely Ee lM behidtl The varedby all aThe cen iral re antl breign oriental(Ns,
cenmedinto ail inciPool and pacdintodsiconeslocal a urn
re0uiredted re The rgamketlram PuMficlbemeWh JIV
centered into Stirecomandplad Mideast
a designated!rahrtainefIXum. CrWabd remains geMrvlly an pulvedxd urNl n0
eirple Ingment b rewgnvable lu ekalWl tiwue.
OPENINGOWTHECONTAINER
The channery may only open the container M1oldhnp the untremmad human remains In limieetl Grmmstanwa,auCh ae to confirm the
Monty of she decausuall Or to ensure Mat no material or induced which marl lnryre employees or damage tM uental pWen¢ It
human remains are school in a container which is not Suitable for narration such as ceremonial or ranked casket,the
romatory will require Mal Me Moain be moved Into a suilabha conkeiner Whore ltacwpb the remains.
mainwdhd oeening of
container or Me transfer or rumored of remains wil MyoudutlM cases,a assume and wil be done in anor and harped.
IDENTIFICATION OF DECE EG
Name of Dewa.ed Dr. Joseph GDt inka Manned
MBWISaWa
35 Valerie Dr., Lake Luzeme, NY 12M
Wst Hncwn Address:
Ptawofoemb: 11 t� of J t' Modica Ia -8 i ion v-1 OS41A
sex. 0 M D F Age oe: I` Da OSdcR
_ o d
Oeauiption dcaskel/mnlenm in which remi we be deiemed.
McDonald Container basic cardboard cremation Container no interior
M"ON IN CONTROL OF Disposal
(PenmoC In Nall Wcommissar, 4uNi ONE NMe MbxNhg)
anJw¢are the designated agent o1 Me tl¢C¢c5N deagnae in a wN or when 'naWmed®euheed pursuant to little
Needs law Section 4301.
k'�M NYe beve nc knm Wge that Me sew W exewled a wriehn inalmmenl pueuoM W PUNM HeaPh taw Sedbn JROl or a
WI conning directions for Me discussion Of his or her remains and awe are Me peaon(q hiving pretty under Public Health taw
$Cman63D1eM hive Me tghlto euNor¢e Cremedon o(M¢Rmalns stile dewa89d. MyMu!r tombipb Medeseaeed Mrs
broker: Dr. Joseph Go anka
DOS16g3f piev. OU15) Paget ol3
Authorization for Cremation and Disposition
ff imerdrw.ingl
M IAsi understand that iI"remains are nM served!ed within 130 days Oluamatbn.
Pine View Crematory
may EBpoOeMMe mmeins in
an laHneuats manner. auh an try amusing. nucmwwr
CREMATION CONTAINERNNN
(/dtial CNENHteldbwirq) t� ,1
An um to be raw as a mntamerM Na comment! remains
s� hems a�d�een�mpurctaud INm♦_]rY/11P ! �I II H pfO R ��
and is descdhed as Idiom 1-3r d
Yang understand thin if the um is tin snarl to had the entry,cremated remains an ar151vs1 raid container may Ire deed f«comedy.
-OR-
Anwar anatympurchesed. W undamWr that Nnoumispur asedorother iisepmvitled
Fine V¢w Crembi
wet pent¢the eremetad remains in
irr..en. e'ei
a and tampo wary comaner air delivery.
Patricia Miller
This AUMplratlon Form was powder by �uxwuxsro was exwaned an
Brewer Funeral Horne, inc.
34 ChuM d "Om Luzeme. Ny 13&6
and is segment Ey,the foraral director as witness to ra meMion^� e
VWe have rtterveb a completed copy of this AU Orly Farm.
The partonts)identified solve Were tlw parson id In control of dissociation,saw by signing this AuManaaOon Form,atlpgsl
b lass accuxy add cwnpletenxs of the IMermatlon widened In this AUMOrtratlm Farm and statements)Me foregoin&
yn Dot a-1 my of �S , >w Lynn
Gob nka ro 6i
35 Valerie Or., lake LdEerne, rvy t2846
mi disease
WITNE%: � 11�
Patricia Millerrese `]Ns1LIl1J
rmnsa.,i
12465
Dr. Joseph Golanka
DOS1696t(Re✓. =15) Page 3 of3
Authorization for Cremation and Disposition
(heart Mae the fiN below)
Number 2 oerptprom spouse
I. AName e«imatee in Vchire Palestine Punk NaWn law F«tlm ode,IS:
2. rM sunrome accord:
22 The command domestic Partner,
s Annrasing tlNd eimaden re an Of age or alder:
a. Aaunirse wren.
5. A aurvlviN vows eighteen rears of ago«older,
s. A mwfuur amounted guardian',
V. Any Persoms)eighteen rears of age or weer entitled m share in me«tale and yiions ctmeat an reletlonanm b me decasa]:
e. Acasefr ewn�ao rpzrr:oathas ee'tdda mi statement
10. A rood naal Mason of a former or a Publk adram«star ammrinkp Partners to iC Sualrgate Section a2ol(7J: '
102 Any inner Person who is amo has swami
ram asumen sttcmn Pracedure Public
hew section am (( gars bMarcormdexeareeand whro n.r aieculed aurllmn statement instrument In Publk Health
(yI AU TNREE m tee gersh irg)
��lnve nerenr arum mar the rosy inure eem«ed ems nor mmam a banerv, banes Pare.poxar mII, redimarve imwam.
attached"deWx and them any auto mebnalawere removed wimmme concede mania AaMorhaffon Form. Fmwra ea Rman
Made Mims Poor cmnatlon many matt in norm m the crematory end cannel posonned.
arm affirm then lMoron Ina have been Panda Miller
Mean to
regaining the removal some Pormnq pmPeM or other thing efvel«xTiM any Mason lunirq salary Of mry family member Must
Piney Crenotory
demanded!wiener heere.ave.
Is net responi forme removal acesonal dams ape Me se, airy or Meetfin¢rerrwna Of Me deseadd. Pardo rul Ions WAS In this
consumer or off Me smai«Mil be d«boyed ray Me cmm"tl past«e and cannot bs mmav«oar cremamd.
AL
ninev crematory
llWa herselfauMORae
mwaar�
m cramatr ds smalno of Me Ee«aeatl.
FINAL OISPOSn1ON
TM Nown ardsmaed to arcane ma chiral rerreina ofine eepasa]man to per«mrv'w:
Name
Buyers Funeral Nome, Inc.
Ades«: 24 Chum St. Lake Ll¢enn Ny 12. 518M'2Tu
Pore'
The gamer remains M dxx«W sill Le ge{aad mad MgmM.
N far dry readers the prawn named doss made Wharf ossarrbn a Me pemnlN remains,
Rw New Csmemry
so aurMrised m man o«a«k Of
matters to Brawx Fumy Ncma, Imrc�rµm
rsn�wrwmsw %elig
ivey
In pram array repi&med mail.
Dr. Joseph Golpnka
008-1896-f(RM, =15) �wesw Pa0e 2 ad3