Bonkowski, Gregory P („1...:F)
Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: 60 f4?),J////'PC-r/�h7 RETURN TIME: /L 7
DATE & TIME REMAINS ARRIVED AT CREMATORY: 7*---- /`Zi Z-oz
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
w SC' t,rn/771-----
NAME: 6rei a r_,` !gip„ 01.vi Sk;. CASE # / P
TYPE OF CONTAINER: -f't-v,J(t9 (<::::)-11 P_ T (;)10 ld 1 Ar) lJOalcl
1tb 4frj rtz7t hi, 43)14 .
PLACE OF DEATH: 9// Si-ale :(itic t Zg,-✓` a Pl7f - U i✓, ,,L'Xi /2g5:3
ESTIMATED WEIGHT OF REMAINS & CONTAINER �(0Ib J '/5.-4 5C- k
PLACED IN HOLD: 7 -
PLACED IN REFRIGERATION:
DATE OF CREMATION: /l-Z 9-- Zo _
TIME STARTED: 75g,-- TIME COMPLETED: iv/-
PLACED IN RETORT: 7 MOVED: 8 1 J
RETORT# IN WHICH REMAINS WERE CREMATED: 54,im- ilJ?r R,4
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.
• N`6v.,27.2023 05:52 PM FRAN BONKOWSKI 3364490570 PAGE. 1/ 5
Nov 27 23,05:21 p Barton McDermott 518-494-2948 p.3
er: t ) ,4) ; I1 he
Naw York Stale
Department of State
47 Department of State r ep e(i 6 133 DIVISION OFcw4ETEg1ES
One Commerce Plaza
TATE Cemeteries 4--„,,per-it NC a 99 Weshh+gton Avenue
Albany,NY 12291.0001
Telephone:(519)474.6226
httpe:l/do6.ny.gov
Authorization for Cremation and Disposition
This Authorization Foes must be completed and signed prior to dainty of remains for ceenotion.
Rare form Is not properly completed or executed,the crematory may reject delivery of the human remans.
NOVEMBER 27,2023 Cane N b�2423-039 q6-/P
Data: nor ovmato4v use orgy)
Crematory Name:PINE VIEW CREMATORIUM
Address:21 QUAKER RD QUEENSBURY, NY 12804 Phone: 518-761-8279
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation Is carried out by placing the remains of the deceased and the container holing the remains into a cremation chamber where
they are subjected to intense heat end flame. The heat and flame will Incinerate and consume everything except bone and metal,
which are all that will be left after cremadon.
Following cremation,the crematory will take reasonable efforts to remove ell of the remains and other material from the cremation
chamber,but some minimal dust and residue rril likely be left behind. The crematory will separate incidental and foreign materiel from
the remains and the Incidental and foreign material,inducting dental work and implants,will be disposed of as permitted by law, The
cremated remains will be mechenlcaly pulverized Into email pieces and placed Into a designated container or urn. Cremated remains
generally are pulverized until no single fragment le recognisable as skeletal tissue.
gENTIFICATION_OF DECEASED
Name of Deceased:
GREGORY P.BONKOWSKI Mental Stett e: SINGLE
Lest Known Address:941 28N NORTH CREEK, NY 12853
Place of Death:Municipality:941 28N NORTH CREEK,NY 12853(TOWN OF CHESTER Slats: NY
Gender: [ M Q F ElX Age:73 BOB.03/11/1950 _ Date of Death:11/2 T/2023 _ Estimated eight
OPINING OF TH>c CONTANER
The crematory may only open the Container holding the un•cremated human remains in limited circumstances,such as to confirm the
Identity of the deceased or to ensure that no material is enclosed which might Injure employees or damage the crematory property. 11
human remains are delivered in a container which Is not suitable for cremation such as ceremonial or rental casket,the crematory will
require that the remains be moved Into a suitable container before it accepts the remains.The opening of a container or the transfer or
removal of remains will be conducted before a witness and will be done In privacy,with dignity end respect.
OESCRIPUQ .QF CONTAINER KIRSCH REMAINS ARE BEING DEUVERED
FLORENCE CASKET COMPANY Cardboard with Heavy Wood Bottom
Manufacturer or suppler: material!
CREMATION CONTAINeR1URM
(LaMar ONE of the following)
1/We have provided with an urn to be used as a container for the
Wens alcrero.tayr
cremated remains.1/We understand that lithe urn is too small to hold the entire cremated remains,an additional rigid
container may be used for delivery,Description of um:
OR•
._Ma have not provided en urn to be used as a container for the cremated remains.and understand that
PINE VIEW CREMATORIUM _ _ win places the cremated remains in
Rhyne or CimitoN
a rigid container for delivery.
DOS-1893-f(Rev.O1123) Page 1 of 3
Nov.•27.2023 05:53 PM FRAN BONKOWSKI 3364490570 PAGE. 2/ 5
Nov 27 23,05:21p Barton McDermott 518.494-2948 p.4
Authorization for Cremation and Disposition
PERSON IN CONJROL OF DISPt IITtOR
(Person(S)rn cord►ol of dlsposalcn,Willi ONE of the following)
I amiWe are the designated agent of the deceased designated in a will or written instrument executed pursuant to Public
Health Law Section 4201.
-OR-
Y � 'ti UWe have no knowledge that the deceased executed a written instrument pursuant to Public Health Law Section 4201 or a
will containing directions for the disposition of his or her remains and Wire are the person(s)having priority under Public
Health Law Section 4201 and have the right to authorize cremation of the remains of the deceased. MylOur relationship
to the deceased Is as follows:
Number 3 Description:CHILD/DAUGHTER/GUARDIAN
2. The surviving spouse;
2s. The surviving domestic partner,
3. Any surviving child eighteen years of age or older,
4. A surviving parent;
5. A surviving sibling eighteen years of ege or older;
6. A lawfully appointed guardian;
7. Any person(s)eighteen years of age or older'Hatted to share in the estate end who Is/are closest to relationship to
the deceased;
a. A duly appointed fiduciary of the estate;
9. A close friend or relative who has executed a written statement pursuant to Public Health Law
Section 4201(7);
Court Procedure
10. A chief fiscal officer of a county or a public adminisustor appointed pursuant to the Surroga
Act;
10a. Any other person who Is acting on behalf of the deceased and who hes executed a wntten statement pursuant to
Public Health Law Section 4201(7).
For numbers 3,b and 7 above,by signing,the person(s)signing this Authorization Form represent that they are signing on behalf of a
majority of the members of this class of persons who are reasonably available.
!lona of the following)
I/W•hereby affirm that the body of the deceased does not contain a battery,battery peck,power cell,radioactive Implant,
or radioactive device and that any such materiels were removed prior to the execution of this Authorization Form. Failure
to remove these Rams prior to cremation may result In harm to the crematory and crematory personnel.
Ma affirm that Instructions have been given to JAMES P. MCDERMOTT.
rowel&sewMane:
regarding the removal of any personal property or other thing of value which any person signing below or any family
member of the deceased wishes to preserve. PINE VIEW CREMATORIUM
Is not responsible for the removal of personal items from the container or from the remains of theixdeceased.
Personal
be lewd
Items loft In the container or with the remains s be destroyed by the cremation prorates and cannot
after cremattlon.
Ur LOPTIONAL)
Icr a hereby f de m d the named In the fu
neral
of theeffuneral dirde for�or,delivery
to end amend tnls fon orm tn o the
crematory.H deemed necessary
correct tome and address of Such alternate crematory.
Name of demised:GREGORY P.BONKOWSKI
DO8-18984(Rev.05/23) Page 2 of 3
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•
Nov 2723,05:21p Barton McDermott 518-494-2948 P.5
Authorization for Cremation and Disposition ,
FINAL DISPOSITIOM
The final resting place for the cremated remains of the deceased is
Q Placement in a grave,crypt,or niche at tpme,ry name)
® Scattering as permitted by law
Other Woe)
The person authorized to receive the cremated remains of the deceased from the cemetery is:
mama) (Ma..o) Mons)
�• W4 " INvs authorize the funeral director executing this Authorization Form.whose Horns appears on page 3 of this form.to receive
1 or send a representative of hie or her funeral firm to receive the cremated remains on my/our behalf.
If for any reason the person named above does not take possession of the cremated remains,
PINE VIEW CREMATORIUM • Is authorized to give possession of
lerwelwyNim.)
the cremated remains toBARTON•WcDERMOTT FUNERAL HOME.1NC.
(fuw*/N.m.Nome)
in person or via delivery by the United States Postal Seniors,as permitted by Its regulations and procedures.
(/=J=a the following)
IIWe understand that It the remains are not Mimed within 120 days of cremation,
PINE VIEW CREMATORIUM
wNaee aaw..IO I
may dispose of the remains In an Irretrievable manner,as permitted by law.
This Authorization Form was provided by JAMES P.MCDERMOTT _ was executed at
((•wolf away Nw.)
BARTON-McDERMOTT FUNERAL HOME,INC.
9y0...r►em.Nam)
9 PINE ST CHESTERTOWN,NY 12817 -------
- (prom Nano Ammo
and is signed by the funeral director as witness to its execution.
INN.have received a completed copy of this Authorization Form.
1Mfe am/are the peasonts)In control of deposition,who by signing this Authortradon Fenn,attest(e)to the accuracy and
completeness of the Information contented In this Authorization Form and hereby authoalio(*)to cremate the remains of the
deceased.
Signed this 27TH day of NOVEMBER ,20 23
PRANCES BONKOWSKi • ..1/11 !, �'
ryp.aa�ibre u Newt f�0� t
5910 SECRETARIAT RD OIBSONVILLE.NC 27240
Aida s
'typo or MAW Nom, soihme
MOUS
UMW CI'Mmrmi Name
lees
WITNESS:
JAMES P. McDERMOTT I
7;;o//PMY.IM r/per arpg4.1. NspN)
12330.
Name of declined:
RY P. BONKOWSKI
DOS•1896 f(Roy.00/23) Page 3 of 3
• Nov,..27.2023 05:54 PM FRAN BONKOWSKI 3364490570 PAGE. 5/ 5
STATE OF NORTH CAROLINA 'F"N°
10E 1256
In The General Court Of Justice
GUILFORD County Superior Court Division
Before The Clerk
IN THE MATTER OF THE ESTATE OF
Nime 0f Were
LETTERS OF APPOINTMENT
EMILY H.O'ROURKE GUARDIAN OF THE PERSON
[]X lncompetanfPoraon ❑Minor G,S.35A-1203,35A-1206,35A-1241
The Court In the exercise of Its Jurisdiction for the appointment of guardians of Incompetent persons and minors, and
upon proper application, has appointed the person(s)named below as Guardian(s) of the Person of the word named
above and has ordered that these Letters Of Appointment be issued.
The guardian of the person Is fully authorized and entitled under the Iews of North Carolina to have the custody, care
and control of the ward, but has no authority to receive, manatee or administer the propertv.•gst fe or business
affairs of the waro.
These Letters are Issued to attest to that authority and to certify that It Is now In full force and effect.
Witness my hand and the Seal of the Superior Court.
Name And Addn»a Of Ou.e.n f 0f TM Person Oar.0f QuMire.$on
FRANCES M.BONKOWSKI aka FRANCES MARY CAVE 04/27/2010
5910 SECRETARIAT ROAD Clerk Of Superior Court
GIBSONVILLE,NC 27249 LISA Y.JOHNSON-TONKINS
EX OFFICIO JUDGE OF PROBATE
Name And Address Of attention 2 Of The Person Oefe Of issuance
06/21/2022
afie
. .
Sign Loa0 u CS Q Atihbnt CSC 0 Of Supa$or Court
SEAL
.
•
NOTE: This latter ia-notialld without the official assl of the Cloth of Superior Cowl.
AOC-E-408,Rev.5/17
C 2017 Administrative Office of the Courts